Cycle 1
Health 2024-10-30 · Fire 2024-10-30
23 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Spokane, WA
Alderwood Manor
3-star overall rating with 2-star inspections with $32,214 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
3600 East Hartson Avenue, Spokane, WA
(509) 535-2071
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1981-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.70
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,274
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.12
Performance 19.52% · Measure score 4.12 · Achievement 4.12 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.33
Baseline 6.07% · Performance 6.84% · Measure score 3.33 · Achievement 3.33 · Improvement 0
Total nurse turnover
0
Baseline 58.49% · Performance 65.15% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.46
Baseline 3.76 hours · Performance 4.06 hours · Measure score 3.46 · Achievement 3.46 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.1% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 6.18% |
| Discharge to community | 53.07% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 47.76% · Lower 95% interval 41.29% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 39 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 83.87% |
53.69%
30.2 pts better
|
Numerator 26 · Denominator 31 |
| Discharge mobility score | 74.19% |
50.94%
23.2 pts better
|
Numerator 23 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 12.37% |
8.2%
4.2 pts better
|
Numerator 12 · Denominator 97 |
| Staff flu vaccination coverage | 18.87% |
42%
23.1 pts worse
|
Numerator 20 · Denominator 106 |
| Discharge function score | 93.55% |
56.45%
37.1 pts better
|
Numerator 29 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 5 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
96.0%
7.5 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 90.9% · Q3 90.4% · Q4 86.3% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.6% |
93.8%
12.2 pts worse
|
95.5%
13.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
2.6%
0.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 1.9% · Q4 2.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.2% |
16.3%
3.9 pts worse
|
11.4%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 25.6% · Q3 30.4% · Q4 8.7% · 4Q avg 20.2% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.8%
0.1 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 11.4% · Q3 1.9% · Q4 8.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
12.1%
16.5 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 29.5% · Q3 19.2% · Q4 32.0% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
15.9%
10.2 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 5.9% · Q3 2.3% · Q4 4.7% · 4Q avg 5.7% · 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 | 8.5% |
20.0%
11.5 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
15.8%
6.7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 17.5% · Q3 10.0% · Q4 2.2% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 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 with new or worsened bowel or bladder incontinence | 22.5% |
23.5%
1 pts better
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 26.0% · Q3 24.6% · Q4 18.1% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
4.7%
2.8 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.9% · Q3 12.4% · Q4 5.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
87.7%
4.4 pts worse
|
81.7%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 85.2% · Q3 83.8% · Q4 75.9% · 4Q avg 83.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
13.2%
5.8 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.1% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.4%
0.7 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3% |
82.0%
1.7 pts worse
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
19.9%
0.4 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 24.3% · Expected 29.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-07 · Fire 2023-07-07
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-10-29 · Fire 2019-10-29
38 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
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 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-10-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-30
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 2024-11-25
D · Potential for more than minimal harm
2024-10-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-25
F · Potential for more than minimal harm
2023-07-07
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-07
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 2023-07-28
D · Potential for more than minimal harm
2023-07-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-28
F · Potential for more than minimal harm
2019-10-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-12-03
F · Potential for more than minimal harm
2019-10-29
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 2019-12-03
F · Potential for more than minimal harm
2019-10-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-03
F · Potential for more than minimal harm
2019-10-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-12-03
E · Potential for more than minimal harm
2019-10-29
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 2019-12-03
E · Potential for more than minimal harm
2019-10-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-03
E · Potential for more than minimal harm
2019-10-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-03
C · Minimal harm
2019-10-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-17
F · Potential for more than minimal harm
2024-10-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-30
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 2024-12-06
E · Potential for more than minimal harm
2024-10-30
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 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
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 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
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 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-30
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 2024-12-06
G · Actual harm
2024-07-26
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 2024-07-26
E · Potential for more than minimal harm
2024-06-12
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 2024-07-12
E · Potential for more than minimal harm
2024-06-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-11-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-09-18
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-10-13
G · Actual harm
2023-07-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-18
G · Actual harm
2023-07-07
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
2023-07-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-07-07
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-07-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-07-07
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
2023-07-07
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
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
D · Potential for more than minimal harm
2023-07-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-07
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
D · Potential for more than minimal harm
2023-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-28
F · Potential for more than minimal harm
2019-10-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F838 · Administration Deficiencies
Health
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.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2019-12-12
E · Potential for more than minimal harm
2019-10-29
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 2019-12-12
E · Potential for more than minimal harm
2019-10-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-12
E · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
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 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-12
Penalties and ownership
What sits behind the stars
$32,214
2023-05-18
Fine
Fine · fine $32,214
Fine
Ownership
Preston, Forrest
5% Or Greater Indirect Ownership Interest · Individual
Fund I Investments Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Alexander, Ken
Operational/Managerial Control · Individual
Butner, Nancy
Operational/Managerial Control · Individual
Consolidated Resources Health Care Fund I LP
Operational/Managerial Control · Organization
Crhc LLC
General Partnership Interest · Organization
Cross, Cindy
Corporate Officer · Individual
Developers Investment Company Inc
Limited Partnership Interest · Organization
Fletcher, Todd
Corporate Officer · Individual
Fund I Investments Limited Partnership
Limited Partnership Interest · Organization
Hcf Inc
Limited Partnership Interest · Organization
Hcf Inc
Operational/Managerial Control · Organization
Henry, Terry
Corporate Officer · Individual
Lay, Lisa
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Moran, Julie
Operational/Managerial Control · Individual
Preston, Aubrey
Operational/Managerial Control · Individual
Snoook, Teresa
Operational/Managerial Control · Individual
Swanker, Richard
Corporate Officer · Individual
Thurmond, Joan
Corporate Officer · Individual
Ziegler, James
Corporate Officer · Individual
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#2
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#3
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3-star overall rating with 3-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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