Cycle 1
Health 2025-09-15 · Fire 2025-09-15
32 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Spokane, WA
Aurora Valley Care
1-star overall rating with 1-star inspections with $94,747 in total fines with 32 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
414 S University Rd, Spokane, WA
(509) 924-4650
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caldera Care
Operator or chain grouping
Approved since
1967-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.62
Baseline 17.46% · Performance 19.75% · Measure score 3.62 · Achievement 3.62 · Improvement 0
Healthcare-associated infections
2.48
Baseline 8.14% · Performance 7.20% · Measure score 2.48 · Achievement 2.11 · Improvement 2.48
Total nurse turnover
1.16
Baseline 68.18% · Performance 60.98% · Measure score 1.16 · Achievement 0.66 · Improvement 1.16
Adjusted total nurse staffing
2.50
Baseline 2.82 hours · Performance 3.71 hours · Measure score 2.50 · Achievement 2.22 · Improvement 2.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 10.29% · Lower 95% interval 7.13% |
| Discharge to community | 49.35% |
50.57%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 38.27% · Lower 95% interval 39.07% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 20 · Denominator 32 |
| Discharge mobility score | 65.63% |
50.94%
14.7 pts better
|
Numerator 21 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 2 · Denominator 47 · Adjusted rate 3.76% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 5.56% |
8.2%
2.6 pts worse
|
Numerator 6 · Denominator 108 |
| Staff flu vaccination coverage | 69.44% |
42%
27.4 pts better
|
Numerator 75 · Denominator 108 |
| Discharge function score | 71.88% |
56.45%
15.4 pts better
|
Numerator 23 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 85% |
96.28%
11.3 pts worse
|
Numerator 17 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 29.63% |
25.2%
4.4 pts better
|
Numerator 8 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.6%
1 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.4% |
16.3%
5.9 pts better
|
11.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 10.6% · Q3 3.3% · Q4 3.6% · 4Q avg 10.4% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.8%
About the same
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 11.6% · Q4 2.9% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
12.1%
5.5 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.5% · Q3 5.8% · Q4 7.2% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
15.9%
8.7 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 25.6% · Q3 25.5% · Q4 21.3% · 4Q avg 24.6% · 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 | 16.2% |
20.0%
3.8 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 33.5% · Q3 4.6% · Q4 8.0% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
15.8%
5 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 20.0% · Q3 7.8% · Q4 7.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.2%
0.2 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.2% · Q3 2.2% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
1.7%
2.3 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.5% · Q3 5.6% · Q4 1.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
23.5%
5 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 26.8% · Q3 32.7% · Q4 22.9% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
4.7%
3.6 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 11.8% · Q3 7.6% · Q4 6.5% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.5% |
87.7%
4.2 pts worse
|
81.7%
1.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 82.1% · Q3 90.6% · Q4 91.3% · 4Q avg 83.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
13.2%
2.3 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 11.6% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.4%
0.9 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.0% |
82.0%
3 pts worse
|
79.7%
0.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
19.9%
1.8 pts worse
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 23.3% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
44 health deficiencies
Top issue: Quality of Life and Care (17 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-20 · Fire 2023-01-20
29 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-09-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-09-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-09-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-09-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-09-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-19
F · Potential for more than minimal harm
2024-06-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-06-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-19
F · Potential for more than minimal harm
2023-01-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-16
F · Potential for more than minimal harm
2023-01-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-02-16
F · Potential for more than minimal harm
2023-01-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-16
F · Potential for more than minimal harm
2023-01-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-02-16
F · Potential for more than minimal harm
2023-01-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-20
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-02-16
D · Potential for more than minimal harm
2023-01-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-16
D · Potential for more than minimal harm
2023-01-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-16
D · Potential for more than minimal harm
2023-01-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-15
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 2025-10-15
F · Potential for more than minimal harm
2025-09-15
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 2025-10-15
F · Potential for more than minimal harm
2025-09-15
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-15
F843 · Administration Deficiencies
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2025-12-01
F · Potential for more than minimal harm
2025-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
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 2025-10-15
E · Potential for more than minimal harm
2025-09-15
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 2025-10-15
E · Potential for more than minimal harm
2025-09-15
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 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-15
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
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 2025-10-15
D · Potential for more than minimal harm
2025-09-15
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 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-03-10
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 2025-04-02
D · Potential for more than minimal harm
2025-02-21
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 2025-03-19
D · Potential for more than minimal harm
2025-02-21
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-03-19
D · Potential for more than minimal harm
2024-12-30
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 2025-01-15
D · Potential for more than minimal harm
2024-12-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
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 2024-11-22
E · Potential for more than minimal harm
2024-09-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-12
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 2024-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-09
G · Actual harm
2024-06-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-06-27
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-06-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
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 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-07-24
G · Actual harm
2024-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-12
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 2024-07-05
D · Potential for more than minimal harm
2024-06-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-12
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 2024-07-05
D · Potential for more than minimal harm
2024-05-09
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 2024-05-24
D · Potential for more than minimal harm
2024-05-09
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-10
C · Minimal harm
2024-04-10
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-07
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 2024-03-06
E · Potential for more than minimal harm
2024-02-16
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 2024-03-05
E · Potential for more than minimal harm
2024-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-10-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-07-06
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 2023-08-02
D · Potential for more than minimal harm
2023-07-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-07-06
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 2023-08-02
D · Potential for more than minimal harm
2023-06-13
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 2023-07-03
G · Actual harm
2023-03-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-27
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 2023-03-28
G · Actual harm
2023-01-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-20
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 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-20
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 2023-03-01
E · Potential for more than minimal harm
2023-01-20
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 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
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 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-01
Penalties and ownership
What sits behind the stars
$93,457
2024-05-09
Fine
Fine · fine $93,457
Fine
$1,290
2023-03-27
Fine
Fine · fine $1,290
Fine
Ownership
Kh7 Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
414 S University Propco LLC
5% Or Greater Mortgage Interest · Organization
Kh7 Hh Cdw
5% Or Greater Indirect Ownership Interest · Organization
Kh7 Ops LLC
5% Or Greater Indirect Ownership Interest · Organization
Logan, Lindsay
Operational/Managerial Control · Individual
Oscherowitz, Raphael
5% Or Greater Indirect Ownership Interest · Individual
Oscherowitz, Raphael
Operational/Managerial Control · Individual
Oscherowitz, Raphael
Corporate Officer · Individual
Palozzolo, Jacqueline
Operational/Managerial Control · Individual
Wolmark, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Wolmark, Chaim
Operational/Managerial Control · Individual
Wolmark, Chaim
Corporate Officer · Individual
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