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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D48 | E20 | F32 |
| Minimal | A· | B· | C1 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Apr 27, 2026 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Apr 27, 2026 | Health | Health Complaint, Health Standard | 19 | Potential harm | — | Open → |
| Mar 10, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Dec 15, 2025 | Fire safety | Fire Safety Complaint | 4 | Potential harm | — | Open → |
| Nov 21, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 17, 2025 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Apr 1, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 21, 2025 | Fire safety | Fire Safety Standard | 5 | Potential harm | — | Open → |
| Jan 21, 2025 | Health | Health Complaint, Health Standard | 21 | Potential harm | — | Open → |
| Nov 12, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 5, 2024 | Fire safety | Fire Safety Complaint | 1 | Potential harm | — | Open → |
| Feb 22, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Sep 12, 2023 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Sep 12, 2023 | Health | Health Standard | 24 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Oct 17, 2025 | Civil money penalty (fine) | $14,613 | — | 385222|Fine|136259 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D48 | E20 | F32 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 27, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 30, 2026 | |
| Apr 27, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2026 | |
| Apr 27, 2026 | K-0347 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
19 facilities in 3 states. CMS chain ID 297.
Chain average overall rating (CMS): 2.6
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Kalesta Healthcare Group, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jun 1, 2025 |
| Scott Clawson | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% | Jun 1, 2025 |
| Ryan Williams | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% | Jun 1, 2025 |
| Scott Clawson | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Jun 1, 2025 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Kalesta Healthcare Group, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jun 1, 2025 |
| Scott Clawson | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% | Jun 1, 2025 |
| Ryan Williams | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% | Jun 1, 2025 |
| Scott Clawson | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Jun 1, 2025 |
| Julie Johansen | Individual |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Willow Creek Post Acute 175 NE 16th Street, Madras, OR 97741 CCN 385181 | 20 | Feb 12, 2026 | 381 harm | — |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Woodland Convalescent Center 310 Fourth Street, Woodland, WA 98674 CCN 505232 | 6.9 km | 62 | Aug 6, 2026 | 671 IJ1 harm | $27k | |
| Avalon Care Center - Scappoose 33910 E. Columbia Avenue, Scappoose, OR 97056 CCN 385283 | 12.2 km | 40 | Apr 3, 2026 | 291 harm | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 385222 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 385222 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected May 30, 2026 |
| Apr 27, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2026 |
| Apr 27, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2026 |
| Apr 27, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2026 |
| Apr 27, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2026 |
| Apr 27, 2026 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2026 |
| Apr 27, 2026 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 1, 2026 | Complaint |
| Apr 27, 2026 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 1, 2026 | Complaint |
| Apr 27, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 | Complaint |
| Apr 27, 2026 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0825 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 1, 2026 | Complaint |
| Apr 27, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 1, 2026 | Complaint |
| Apr 27, 2026 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Jun 1, 2026 |
| Apr 27, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Jun 1, 2026 |
| Mar 10, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 21, 2026 | Complaint |
| Mar 10, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 21, 2026 | Complaint |
| Mar 10, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 21, 2026 | Complaint |
| Dec 15, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 10, 2026 | Complaint |
| Dec 15, 2025 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 10, 2026 | Complaint |
| Dec 15, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 10, 2026 | Complaint |
| Dec 15, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 10, 2026 | Complaint |
| Nov 21, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| Oct 17, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | G · Actual harm Isolated | Corrected Nov 7, 2025 | Complaint |
| Apr 1, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 1, 2025 | Complaint |
| Jan 21, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | E-0020 | Establish policies and procedures including evacuation. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 28, 2025 | Complaint |
| Jan 21, 2025 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 28, 2025 | Complaint |
| Jan 21, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 28, 2025 | Complaint |
| Jan 21, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 28, 2025 | Complaint |
| Jan 21, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 28, 2025 | Complaint |
| Jan 21, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 28, 2025 | Complaint |
| Jan 21, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Jan 21, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Nov 12, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 13, 2024 | Complaint |
| Nov 12, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 13, 2024 | Complaint |
| Jun 5, 2024 | K-0300 | Meet other general requirements that are deficient. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 10, 2024 | Complaint |
| Feb 22, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 18, 2024 | Complaint |
| Feb 22, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 18, 2024 | Complaint |
| Sep 12, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Oct 25, 2023 |
| Sep 12, 2023 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0680 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0801 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 25, 2023 |
| Sep 12, 2023 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 25, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.84 (case-mix index 1.21).
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Sep 13, 2023 |
| Stephen Sanchez | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 20, 2015 |
| Scott Clawson | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 1, 2025 |
| Ryan Williams | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 1, 2025 |
| Julie Johansen | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 1, 2025 |
| Stephen Sanchez | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 1, 2025 |