Cycle 1
Health 2024-11-17 · Fire 2024-11-17
12 health deficiencies
Top issue: Resident Rights (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Pullman, WA
Three Creeks Post Acute
2-star overall rating with 2-star inspections with $60,385 in total fines with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Northwest 1310 Deane, Pullman, WA
(509) 332-1566
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
21
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caldera Care
Operator or chain grouping
Approved since
1979-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.32
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.44
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,558
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.49
Baseline 18.04% · Performance 19.81% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Healthcare-associated infections
6.46
Baseline 5.69% · Performance 5.90% · Measure score 6.46 · Achievement 6.46 · Improvement 0
Total nurse turnover
2.03
Baseline 71.88% · Performance 60.00% · Measure score 2.03 · Achievement 0.9 · Improvement 2.03
Adjusted total nurse staffing
3.81
Performance 4.16 hours · Measure score 3.81 · Achievement 3.81 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 7.69% · Lower 95% interval 7.02% |
| Discharge to community | 53.26% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 50% · Lower 95% interval 45.49% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.86% |
95.27%
2.4 pts worse
|
Numerator 52 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 16 · Denominator 32 |
| Discharge mobility score | 43.75% |
50.94%
7.2 pts worse
|
Numerator 14 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.9% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 0% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 59.26% |
8.2%
51.1 pts better
|
Numerator 32 · Denominator 54 |
| Staff flu vaccination coverage | 33.87% |
42%
8.1 pts worse
|
Numerator 21 · Denominator 62 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 16 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.3% |
96.28%
5 pts worse
|
Numerator 21 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 3.57% |
25.2%
21.6 pts worse
|
Numerator 1 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.4
0.9 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.7 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.5
1.9 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 4.4 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
96.0%
2 pts worse
|
93.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.8% · Q3 85.7% · 4Q avg 94.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
93.8%
0.5 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
16.3%
10.1 pts better
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
5.8%
4.7 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 18.2% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
12.1%
1.7 pts worse
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 8.7% · Q3 20.0% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
15.9%
6.2 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.8% |
20.0%
4.8 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
15.8%
6.7 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.8% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.2%
1.4 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.7%
0.8 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.8% |
23.5%
12.7 pts better
|
19.8%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 13.8% · 4Q avg 10.8% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.7%
1.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.0% · Q3 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.9% |
87.7%
17.8 pts worse
|
81.7%
11.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 77.8% · Q3 67.3% · Q4 57.1% · 4Q avg 69.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.0% |
13.2%
9.8 pts worse
|
12.0%
11 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 25.5% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.4%
0.6 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
82.0%
32 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
19.9%
5.2 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 25.5% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-19 · Fire 2023-08-19
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-23
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2026-01-28
F · Potential for more than minimal harm
2025-12-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-28
F · Potential for more than minimal harm
2024-11-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-11-17
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-11-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-08-19
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-08-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-08-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-08-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-20
F · Potential for more than minimal harm
2021-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-07
F · Potential for more than minimal harm
2021-09-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-24
F · Potential for more than minimal harm
2021-09-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-09-24
Inspection history
Recent health citations
L · Immediate jeopardy
2025-12-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-28
C · Minimal harm
2025-12-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-11-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-11-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-09
E · Potential for more than minimal harm
2025-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-11-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-17
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-17
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-12-23
G · Actual harm
2024-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-19
D · Potential for more than minimal harm
2023-12-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-10-02
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-10-17
E · Potential for more than minimal harm
2023-08-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-07-24
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-16
L · Immediate jeopardy
2021-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-19
L · Immediate jeopardy
2021-09-10
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-10-19
G · Actual harm
2021-09-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-10-19
E · Potential for more than minimal harm
2021-09-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-10-19
E · Potential for more than minimal harm
2021-09-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-10-19
E · Potential for more than minimal harm
2021-09-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-10-19
B · Minimal harm
2021-09-10
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2021-10-19
Penalties and ownership
What sits behind the stars
$28,210
2025-11-10
Fine
Fine · fine $28,210
Fine
$0
2025-11-10
Payment Denial
Payment Denial · denial start 2026-02-06 · 3 days
3 day denial
$32,175
2024-05-01
Fine
Fine · fine $32,175
Fine
Ownership
Washington 3 Pack LLC
5% Or Greater Direct Ownership Interest · Organization
Gutierrez-Ritari, Audra
W-2 Managing Employee · Individual
Handler, Asher
5% Or Greater Indirect Ownership Interest · Individual
Oscherowitz, Raphael
5% Or Greater Indirect Ownership Interest · Individual
Oscherowitz, Raphael
Corporate Officer · Individual
Rop Care Ajh LLC
5% Or Greater Indirect Ownership Interest · Organization
Rop Opco Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wolmark, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Wolmark, Chaim
Corporate Officer · Individual
Wolmark, Chaim
W-2 Managing Employee · Individual
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