Cycle 1
Health 2025-06-20 · Fire 2025-06-20
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Woodland, WA
Woodland Convalescent Center
4-star overall rating with 4-star inspections with $17,778 in total fines with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
310 Fourth Street, Woodland, WA
(360) 225-9443
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.78
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.62
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
3.69
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 7.01% |
| Discharge to community | 45.87% |
50.57%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 36.36% · Lower 95% interval 29.61% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 34.78% |
50.94%
16.2 pts worse
|
Numerator 8 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 28.21% |
8.2%
20 pts better
|
Numerator 33 · Denominator 117 |
| Staff flu vaccination coverage | 73.94% |
42%
31.9 pts better
|
Numerator 105 · Denominator 142 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 11 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
93.8%
4.3 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
16.3%
10.8 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 10.9% · Q3 2.3% · Q4 4.2% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
5.8%
3.9 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 13.5% · Q3 11.1% · Q4 10.8% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
12.1%
10 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 26.3% · Q3 21.1% · Q4 20.5% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
15.9%
2.3 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.6% · Q3 15.6% · Q4 20.0% · 4Q avg 18.2% · 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 | 35.9% |
20.0%
15.9 pts worse
|
16.3%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
15.8%
0.9 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 15.2% · Q3 11.1% · Q4 10.8% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.2%
0.9 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 2.3% · Q4 1.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
23.5%
6.4 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 28.7% · Q3 45.8% · Q4 18.1% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.7%
0.7 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.6% · Q3 5.8% · Q4 4.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.7%
12.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
13.2%
1.8 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
82.0%
12.4 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.9% |
19.9%
5 pts better
|
23.9%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.3% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
31 fire-safety deficiencies
Top issue: Emergency Preparedness (20 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-23
F · Potential for more than minimal harm
2025-06-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-06-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-06-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-23
F · Potential for more than minimal harm
2025-06-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-13
F · Potential for more than minimal harm
2025-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-06-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-23
F · Potential for more than minimal harm
2025-06-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-06-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-23
E · Potential for more than minimal harm
2025-06-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-06-20
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-06-20
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 2025-06-23
F · Potential for more than minimal harm
2024-05-03
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-03
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 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-05-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-05-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-03
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 2024-05-24
D · Potential for more than minimal harm
2024-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-24
F · Potential for more than minimal harm
2023-04-20
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
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 2023-05-17
F · Potential for more than minimal harm
2023-04-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-04-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-04-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-04-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-04-20
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 2023-05-17
F · Potential for more than minimal harm
2023-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-08
E · Potential for more than minimal harm
2023-04-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-04-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-20
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 2025-08-01
E · Potential for more than minimal harm
2025-06-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-19
E · Potential for more than minimal harm
2025-06-20
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 2025-07-18
D · Potential for more than minimal harm
2025-06-20
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-05-21
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-05-03
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 2024-06-21
E · Potential for more than minimal harm
2024-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-03
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 2024-06-21
D · Potential for more than minimal harm
2024-05-03
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 2024-06-21
D · Potential for more than minimal harm
2024-05-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-21
J · Immediate jeopardy
2023-10-27
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 2023-11-17
E · Potential for more than minimal harm
2023-04-20
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 2023-06-13
E · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-04-20
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 2023-06-13
D · Potential for more than minimal harm
2023-04-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-13
Penalties and ownership
What sits behind the stars
$0
2025-06-20
Payment Denial
Payment Denial · denial start 2025-09-20 · 23 days
23 day denial
$17,778
2023-10-27
Fine
Fine · fine $17,778
Fine
Ownership
Chinn, Larry
Operational/Managerial Control · Individual
Clay, Bryan
Operational/Managerial Control · Individual
Evergreen Living Centers, Inc
Operational/Managerial Control · Organization
Hayes, Candy
W-2 Managing Employee · Individual
Kaser, Brandon
W-2 Managing Employee · Individual
Settlemier, Caroline
5% Or Greater Direct Ownership Interest · Individual
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