Cycle 1
Health 2025-07-25 · Fire 2025-07-25
5 health deficiencies
Top issue: Environmental (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Yakima, WA
Willow Springs Care And Rehabilitation
5-star overall rating with 5-star inspections with $21,442 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4007 Tieton Drive, Yakima, WA
(509) 966-4500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hyatt Family Facilities
Operator or chain grouping
Approved since
1990-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 health / 4 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
0.97
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,896
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.51
Baseline 22.49% · Performance 21.39% · Measure score 1.51 · Achievement 0 · Improvement 1.51
Healthcare-associated infections
1.13
Baseline 5.78% · Performance 7.50% · Measure score 1.13 · Achievement 1.13 · Improvement 0
Total nurse turnover
0
Baseline 43.64% · Performance 66.35% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.28
Baseline 3.03 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.94% |
10.72%
2.8 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 1.69% · Lower 95% interval 4.86% |
| Discharge to community | 60.76% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 131 · Observed rate 58.02% · Lower 95% interval 52.91% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 2.3% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 87 |
| Discharge self-care score | 58.06% |
53.69%
4.4 pts better
|
Numerator 36 · Denominator 62 |
| Discharge mobility score | 59.68% |
50.94%
8.7 pts better
|
Numerator 37 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 5.75% |
2.29%
3.5 pts worse
|
Numerator 5 · Denominator 87 · Adjusted rate 5.62% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 7.59% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 0.96% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 104 |
| Staff flu vaccination coverage | 61.64% |
42%
19.6 pts better
|
Numerator 90 · Denominator 146 |
| Discharge function score | 59.68% |
56.45%
3.2 pts better
|
Numerator 37 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 97.73% |
96.28%
1.5 pts better
|
Numerator 43 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 12 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.4
0.3 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.7 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
96.0%
2.8 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.7% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 2.2% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.9% |
16.3%
2.6 pts worse
|
11.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.2% · Q3 30.4% · Q4 30.2% · 4Q avg 18.9% |
| Percentage of long-stay residents who lose too much weight | 23.7% |
5.8%
17.9 pts worse
|
5.4%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 17.2% · Q3 29.0% · Q4 20.0% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.3% |
12.1%
4.8 pts better
|
19.6%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 9.4% · Q4 15.2% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
15.9%
2.8 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 26.1% · Q3 16.7% · Q4 20.0% · 4Q avg 18.7% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.1% |
20.0%
10.1 pts worse
|
16.3%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
15.8%
0.2 pts worse
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 29.0% · Q4 18.8% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.0% |
1.2%
3.8 pts worse
|
1.0%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 0.0% · Q3 8.4% · Q4 4.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
1.7%
4.3 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.7% · Q3 4.4% · Q4 2.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.3% |
23.5%
6.8 pts worse
|
19.8%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 27.7% · Q3 39.0% · Q4 25.7% · 4Q avg 30.3% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.7%
2.3 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 13.4% · Q3 4.9% · Q4 1.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
87.7%
4.6 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 95.6% · Q3 85.7% · Q4 90.8% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.1% |
13.2%
12.9 pts worse
|
12.0%
14.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 25.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
1.4%
4 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.8% · Q3 6.8% · Q4 8.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
82.0%
11.4 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
19.9%
10.2 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 28.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-10 · Fire 2024-09-10
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2023-07-22 · Fire 2023-07-22
23 health deficiencies
Top issue: Resident Rights (8 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-20
F · Potential for more than minimal harm
2025-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-20
F · Potential for more than minimal harm
2025-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-20
F · Potential for more than minimal harm
2025-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-20
F · Potential for more than minimal harm
2025-07-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-25
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 2025-08-20
D · Potential for more than minimal harm
2025-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-20
F · Potential for more than minimal harm
2024-09-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-09-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-09-10
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-09-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-09-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-07-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-22
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-19
F · Potential for more than minimal harm
2023-07-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-25
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 2025-09-03
E · Potential for more than minimal harm
2025-07-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-25
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 2025-09-03
D · Potential for more than minimal harm
2025-07-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-09-03
C · Minimal harm
2025-07-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-03
E · Potential for more than minimal harm
2024-09-10
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-09-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-09-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-09-10
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 2024-10-12
D · Potential for more than minimal harm
2024-09-10
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-09-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-08-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-14
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-06
J · Immediate jeopardy
2023-07-22
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 2023-08-18
F · Potential for more than minimal harm
2023-07-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-22
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-22
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 2023-08-18
E · Potential for more than minimal harm
2023-07-22
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 2023-08-18
E · Potential for more than minimal harm
2023-07-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
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 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
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 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-22
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 2023-08-18
Penalties and ownership
What sits behind the stars
$21,442
2023-07-22
Fine
Fine · fine $21,442
Fine
Ownership
Berk, Heidi
W-2 Managing Employee · Individual
Cleveland, Michael
Corporate Director · Individual
Hyatt Family Facilities LLC
5% Or Greater Direct Ownership Interest · Organization
Hyatt, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Hyatt, Norman
5% Or Greater Direct Ownership Interest · Individual
Repp, Rebecca
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Summitview Rehab And Health Center
Yakima, WA
4-star overall rating with 3-star inspections with $223,288 in total fines with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Crescent Health Care
Yakima, WA
3-star overall rating with 3-star inspections with $173,932 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Landmark Care And Rehabilitation
Yakima, WA
1-star overall rating with 1-star inspections with $132,702 in total fines with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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