Home / Washington / Port Orchard
2051 Pottery Avenue, Port Orchard, WA 98366 · Kitsap County · (360) 876-4461
96 certified beds, about 78 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1972
CMS Care Compare ratings, data as of September 1, 2026 · CCN 505217 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 12, 2025, inspectors cited 5 health deficiencies (the Washington average is 15.8, the national average 9.2).
Of 33 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.02 hours per resident per day, against 4.36 across Washington and 3.86 nationally. Registered nurses accounted for 0.62 of those hours.
43.0% of nursing staff left within the year CMS measured (Washington average 45.1%).
CMS links it to Avamere, an affiliated group of 27 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 33 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure results of allegations/investigations were reported to the State Agency Hotline within 5 working days for 2 of 2 residents (1 & 2) reviewed for abuse and neglect. This failure placed residents at risk for potential unmet needs and decreased quality of life.
Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had an adequate indication for use, the specific target behaviors (TB) the medication was implemented to treat were identified and monitored, gradual dose reductions (GDRs) were performed and resident responses accurately assessed and documented, non-drug interventions were identified and attempted prior to administration of as needed (PRN) psychotropic medications, and staff monitoring for medication adverse side effects occurred for 3 of 5 residents (Residents 13, 44 & 26) reviewed for unnecessary medications. These failures detracted from staff's ability to assess the effectiveness of psychotropic medication(s), need for ongoing use and presence of medication adverse side effects (ASEs). [...]
Inspectors wroteBased on interview and record review, the facility failed to provide a transfer notice and written bed hold notice at the time of transfer to the hospital, for 3 of 3 sampled residents (Resident 24, 73 & 2) reviewed for hospitalization. This failure placed residents at risk for not knowing their rights to transfers or of bed holds while in the hospital and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to provide bowel care in accordance with physician orders and the facility bowel protocol for 2 of 6 residents (Residents 6 & 36) reviewed for bowel management, to replace tube feeding syringes every 24 hours as ordered for 1 of 1 resident (Resident 79) reviewed for tube feeding, and to ensure non-pharmacological interventions (NPIs, non-medication interventions aimed to decrease pain) were attempted prior to administration of as needed (PRN) pain medication for 2 of 5 residents (Residents 44 & 26) reviewed for unnecessary medications. These failures placed residents at risk for unmet care needs, possible complications, and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated in accordance with accepted professional standards of practice, and expired medications were discarded for 1 of 2 medication rooms and 1 of 2 medication carts (300 Hall medication room and medication cart) that were observed. These failures placed residents at risk to receive expired medications and negative health outcomes.
Inspectors wroteBased on observation and interviews, the staff failed to maintain infection control practice by transporting linen covered and performing hand hygiene when delivering clothes from room to room in 4 of 4 hallways (100, 200, 300 and Transitional Care (TC)) observed. These failures placed all residents at risk of an infection and diminished health.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for catheter removal and coordination with urology occurred timely for 1 of 3 residents (Resident 1) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to obtain clarification for treatment and assess timely for prompt intervention, a surgical incision under the dressing for 1 of 3 residents (Resident 1) reviewed for wound care. Resident 1 experienced harm when their surgical incision dehisced (opened back up), became necrotic (dead/devitalized tissue) and showed signs of infection after 19 days without observation of the incision below the dressing assessment. This failure placed residents at risk for medical complications and a decreased quality of life.
Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable and homelike environment on 1 of 4 hallways (200 hall). The failure to ensure hallway carpeting was clean and in good repair and resident rooms were mopped and free of sticky substances, placed resident at risk for a diminished quality of life, and resulted in a less than homelike environment.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 63) reviewed for communication and sensory and who required assistive devices for vision or hearing were assisted with application of their glasses. Failure to ensure their glasses were in good repair and applied to the resident daily precluded the resident from reading the activity calendar and menus independently and placed them at risk for feelings of diminished self worth and decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 5 of 8 residents (Residents 65, 32, 25, 10 and 13) reviewed for bowel management. The failure to initiate bowel care in accordance with physician's orders placed residents at risk for pain/discomfort, nausea, decreased appetite and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 3 of 3 residents (Residents 16, 48 & 74) reviewed for IV therapy. The failure to ensure IV orders included routine monitoring of IV insertion sites, flush orders, weekly changes of IV dressings and needleless injection caps, and initial and then weekly measurements of IV catheters external length and the residents arm circumferences, placed them at risk for loss of vascular access, infection, and other potential negative health outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to assure residents received foods in the appropriate form and/or nutritive content as prescribed by a physician for 5 of 36 sampled residents (Resident 57, 22, 10, 52 & 74) reviewed for diet requirements. Failure to ensure residents' received physician ordered therapeutic diets or portion sizes placed residents at risk for medical complications or nutritional deficits.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 11 of 11 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide residents a written notice detailing the reasons for discharge/transfer and to provide a copy of the notice to the state Ombudsman office as required for 2 of 2 sampled residents (Resident 27 & 75) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds.
Inspectors wroteBased on interview and record review, the facility failed to provide Care Conferences (a conference where staff and residents/families talk about life in the facility, review the progress of resident and make adjustments, as needed, to their care), for 1 of 2 sampled residents (Resident 13) reviewed for provision of care conferences, and failed to ensure care plans were reviewed, revised, and accurately reflected resident care needs for 4 of 21 sample residents (Residents 16, 48, 63, & 8) reviewed for care plan timing and revision. These failures placed residents at risk of not feeling involved in the development of their plan of care, unmet needs, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include providing oral care and assistance with shaving for 2 of 2 residents (Residents 63 and 10) reviewed for ADL's. The failure to assist dependent residents with oral care and shaving, placed residents at risk for embarrassment, dental caries, powerlessness and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure non-invasive mechanical ventilation via continuous positive airway pressure machines (CPAP, an external device that provides a fixed pressure to keep breathing airways open while you sleep) was provided in accordance with accepted professional standards of practice for 2 of 2 residents (Resident 25 & 63) reviewed for respiratory care. The failure to ensure active CPAP orders were in place and complete, to include the prescribed pressure settings, type of mask (e.g. nasal pillows, nasal mask, full face mask) to be used, direction to check and refill the humidifier reservoir, and the solution to be used to refill it, placed residents at risk for ineffective assisted ventilation and unmet respiratory needs.
Inspectors wroteBased on interview and record review, the facility failed to provide medication administration consistent with professional standards of nursing practice for 2 of 5 residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for unmet care needs, diminished quality of life and potential for medical complications.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of phorid flies (a type of fly that breed in moist, decaying organic matter) in 3 of 4 resident care units (Hallway 100, 200 and 300), kitchen, dining room and common areas of the facility. This failure placed residents at risk for infection, distress and a decreased quality of life.
Inspectors wroteResident 51 Review of Resident 51's admission Minimum Data Set (MDS, a required assessment tool) dated 03/12/2021, showed Resident 51 admitted on [DATE] with multiple health conditions including stroke and muscle weakness. The MDS further showed that the resident required extensive assistance with activities of daily living (ADL). Review of Resident 51's care plan dated 07/05/2023 showed that the resident required assistance with ADLs related to decreased mobility and weakness. The resident's goal was to participate in active assistive range of motion (AAROM) program to bilateral lower extremities (BLE) to prevent tone or contractures. In addition, staff were to implement these interventions one to two times per week. Multiple observations on 09/18/2023 at 9:35 AM, 09/18/2023 at 2:15 PM, and 9/19/2023 at 11:11 AM, showed Resident 51 was either in bed sleeping or watching television. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain resident refrigerators to ensure temperatures were withing safe ranges for 2 of 4 refrigerators (room [ROOM NUMBER] and 203) when reviewed for Kitchen. This failure placed residents at risk of consuming expired food items, foodborne illness, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident food preferences for 1 of 3 residents (Resident 61) reviewed for Choices. This failure placed the resident at risk of reduced nutritional intake, undesired weight loss, a lack of enjoyment in eating, and a diminished quality of life.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to notify the physician for one of four residents (Resident (R) 30) reviewed for medication errors who missed seizure medications. This failure placed residents at risk for health complications and a diminished quality of life.
Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to develop a baseline care plan to include catheter use based on physician orders for one of two residents (Resident (R) 175) reviewed for catheter care. Failure to ensure an initial care plan addressed catheter care placed residents at potential risk for unmet needs, medical complications and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of 25 residents (Residents 276) whose care plans were reviewed. Failure to establish care plans that accurately reflected assessed care needs, resident desired outcomes/goals, and provide direction to staff (interventions) related to activities placed residents at risk to receive less than adequate care.
Inspectors wrote3. Review of R176's Clinical Census, located in the EMR under the Census tab, revealed an admission date of 09/07/23 with medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction and paraplegia. Review of R176's admission MDS located in the EMR under the MDS tab with an ARD of 09/12/23 revealed a BIMS score of 15 out of 15, indicating R176 was cognitively intact. The MDS revealed R176 required extensive physical assistance of two+ persons for bed mobility and transfers. During an observation and interview on 09/18/23 at 10:51 AM, R176 was observed in her room in bed. R176 stated she was admitted after a stroke. R176 stated she had been paralyzed 30 years, incomplete quad cervical fracture. I could use my left arm, but the stroke took that away. [...]
Inspectors wrote2. Multiple observations throughout the day on 09/19/2023 and 09/20/2023 showed Resident 276 self-propelled in their wheelchair to the sidewalk adjacent to the facility to smoke a cigarette. Upon returning to the building the resident put their lighter and cigarettes in a small purse which was hanging on the wheelchair and returned to their room. Review of Resident 276's Electronic Health Record showed progress notes on 04/17/2023 that indicated the resident advised the Director or Nursing that they had no intention to stop smoking. On 05/26/2023 Resident 276 was observed smoking and reminded by staff of the non-smoking policy. On 07/12/2023 at the quarterly care conference Resident 276 was reminded about the non-smoking policy and informed that they would have to sign the non-smoking agreement. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a therapeutic diet as ordered for 1 of 5 residents (Resident 61) when reviewed for Nutrition. This failure placed residents at risk for difficulty eating, possible choking hazard, reduced nutritional intake, unintended weight loss, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen services were provided in accordance with professional standards of practice for 1 of 1 resident (Residents 275) reviewed for respiratory care. Failure to ensure there was a Physician's order for oxygen placed the resident at risk for unmet care needs and potential negative outcomes.
Inspectors wroteBased on interview, the facility failed to maintain sufficient staffing levels to provide exercise programs to maintain/prevent range of motion for 3 of 5 residents (Residents 9, 51, and 276) when reviewed for Sufficient Nurse Staffing. Failure to maintain staffing to provide these services placed residents at risk of deconditioning, loss of range of motion, inability to complete activities of daily living (ADL), and a diminished quality of life.
Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to prevent significant medication errors for two of four residents (Residents (R)30 and R59) reviewed for medication errors. The facility failed to administer Clobazam (used to treat seizure disorder) between 08/18/23 and 08/24/23 with R30 experiencing a seizure on 08/24/23 and failed to administer Clobazam according to physician order for R59. This failure placed residents at risk for health complications and a diminished quality of life.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to detect and discard unopened, expired medications from one of two medication storage rooms reviewed. These failures placed residents at potential risk for receiving compromised or ineffective medications with unknown potency
25 fire safety citations on file: 5 on September 12, 2025, 1 on July 31, 2025, 11 on August 27, 2024, 8 on September 21, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Washington | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.02 | 4.36 | 3.86 |
| Registered nurses | 0.62 | 0.94 | 0.69 |
| All nursing staff on weekends | 3.66 | 3.80 | 3.42 |
| Nurse aides | 2.39 | ||
| Licensed practical nurses | 1.01 | ||
| Nursing staff turnover (share who left in a year) | 43.0% | 45.1% | 45.8% |
| Registered nurse turnover | 38.5% | 45.4% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.66 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.17 on weekdays and 3.66 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.46 in April to June 2025 to 4.02 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.02 | 0.62 | 4.17 | 3.66 | 0.9% | 0 of 90 | 78 |
| Oct to Dec 2025 | 4.27 | 0.63 | 4.44 | 3.83 | 0.0% | 0 of 92 | 75 |
| Jul to Sep 2025 | 4.30 | 0.60 | 4.45 | 3.92 | 0.0% | 0 of 92 | 72 |
| Apr to Jun 2025 | 4.46 | 0.61 | 4.66 | 3.98 | 0.4% | 0 of 91 | 69 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Washington, Jan to Mar 2026 | 4.21 | 0.90 | 4.44 | 3.66 | 3.7% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Washington, all employers | |||
| CNAs (nursing assistants) | $23.65 | $22.59 to $27.85 | 30,270 |
| LPNs and LVNs | $39.98 | $36.98 to $45.18 | 6,780 |
| Registered nurses | $59.71 | $49.57 to $64.54 | 69,260 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Washington | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.9 | 14.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.0 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.3 | 2.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.3 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.5 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.4 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.5 | 15.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 28.6 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 21.2 | 13.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Avamere Rehabilitation at Ridgemont's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (64.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
64.5% this home
Better than the national rate
US median of homes 51.5% · Washington: 71 better, 16 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 297 eligible stays.
9.7% this home
No different from the national rate
US median of homes 10.7% · Washington: 7 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 264 eligible stays.
5.0% this home
No different from the national rate
US median of homes 7.1% · Washington: 4 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 128 eligible stays.
68.6% this home
Median of homes: Washington61.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 70 residents counted.
0.7% this home
Median of homes: Washington0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 143 residents counted.
1.1% this home
Median of homes: Washington1.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 143 residents counted.
100.0% this home
Median of homes: Washington98.3% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 38 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: PO SNF OPERATIONS LLC. CMS links this home to Avamere, a group of 27 nursing homes averaging 3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Nair SNF Operations LLC | 5% or greater direct ownership interest | Organization | 100% | 05/22/2023 |
| Nair Facility Holdings LLC | 5% or greater indirect ownership interest | Organization | 05/22/2023 | |
| Nair LLC | 5% or greater indirect ownership interest | Organization | 05/22/2023 | |
| Nair Operations LLC | 5% or greater indirect ownership interest | Organization | 05/22/2023 | |
| Dillon, Richard | 5% or greater indirect ownership interest | Individual | 05/22/2023 | |
| Odermott, Ronald | 5% or greater indirect ownership interest | Individual | 05/22/2023 | |
| Kretchmar, Joshua | Contracted managing employee | Individual | 11/01/2023 | |
| Carlston, Scott | W-2 managing employee | Individual | 05/06/2024 | |
| Kofstad, Mary | Corporate officer | Individual | 02/13/2024 | |
| Simpson, Andrew | Corporate officer | Individual | 06/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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