Cycle 1
Health 2025-06-09 · Fire 2025-06-09
28 health deficiencies
Top issue: Resident Rights (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Shelton, WA
Fir Lane Care
1-star overall rating with 1-star inspections with $138,648 in total fines with 28 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2430 North 13th Street, Shelton, WA
(360) 426-1651
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caldera Care
Operator or chain grouping
Approved since
1980-01-01
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
0.63
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,545
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.81
Composite VBP score used to determine payment impact.
Payment multiplier
1.0109
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.29
Baseline 18.45% · Performance 17.13% · Measure score 9.29 · Achievement 9.29 · Improvement 8.82
Healthcare-associated infections
6.23
Baseline 7.65% · Performance 5.97% · Measure score 6.23 · Achievement 6.23 · Improvement 5.82
Total nurse turnover
4.51
Baseline 72.73% · Performance 48.75% · Measure score 4.51 · Achievement 3.65 · Improvement 4.51
Adjusted total nurse staffing
2.3
Baseline 2.97 hours · Performance 3.73 hours · Measure score 2.3 · Achievement 2.3 · Improvement 2.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.08% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 5.88% · Lower 95% interval 5.88% |
| Discharge to community | 32.9% |
50.57%
17.7 pts worse
|
Worse than the National Rate · Eligible stays 126 · Observed rate 26.98% · Lower 95% interval 25.78% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.75% |
95.27%
1.5 pts worse
|
Numerator 90 · Denominator 96 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 96 |
| Discharge self-care score | 66.1% |
53.69%
12.4 pts better
|
Numerator 39 · Denominator 59 |
| Discharge mobility score | 38.98% |
50.94%
12 pts worse
|
Numerator 23 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 5.21% |
2.29%
2.9 pts worse
|
Numerator 5 · Denominator 96 · Adjusted rate 5.08% |
| Healthcare-associated infections requiring hospitalization | 5.97% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 2.99% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 12.22% |
8.2%
4 pts better
|
Numerator 11 · Denominator 90 |
| Staff flu vaccination coverage | 31.78% |
42%
10.2 pts worse
|
Numerator 41 · Denominator 129 |
| Discharge function score | 52.54% |
56.45%
3.9 pts worse
|
Numerator 31 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 96.88% |
96.28%
0.6 pts better
|
Numerator 31 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 17.19% |
25.2%
8 pts worse
|
Numerator 11 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
96.0%
10.1 pts worse
|
93.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 91.2% · Q3 85.1% · Q4 71.0% · 4Q avg 85.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
93.8%
1.6 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 1.5% · Q4 1.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
16.3%
10.4 pts better
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.8% · Q3 3.7% · Q4 8.3% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.8%
1.8 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.2% · Q3 6.8% · Q4 7.4% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
12.1%
4.4 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 17.5% · Q3 17.7% · Q4 14.3% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.3% |
15.9%
20.4 pts worse
|
16.7%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.2% · Q2 38.6% · Q3 39.6% · Q4 29.5% · 4Q avg 36.3% · 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 | 11.6% |
20.0%
8.4 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 20.9% · Q3 4.0% · Q4 3.7% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
15.8%
4.5 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 15.3% · Q3 3.4% · Q4 5.7% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.2%
0.7 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 1.6% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
23.5%
1.5 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 16.9% · Q3 30.6% · Q4 22.0% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
4.7%
6.8 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 11.9% · Q3 17.3% · Q4 8.7% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.3% |
87.7%
17.4 pts worse
|
81.7%
11.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.8% · Q2 65.4% · Q3 65.9% · Q4 75.4% · 4Q avg 70.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
13.2%
2.1 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 15.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.4%
0.3 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.8% · Q3 1.5% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.4% |
82.0%
30.6 pts worse
|
79.7%
28.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
19.9%
4.9 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 25.0% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2024-05-10
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-06-09 · Fire 2023-06-09
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-09
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 2025-07-09
F · Potential for more than minimal harm
2025-06-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-09
F · Potential for more than minimal harm
2024-05-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-05-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-05-10
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-05-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-05-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-05
F · Potential for more than minimal harm
2023-06-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-06-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-06-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-06-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-21
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 2025-09-10
D · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-06-09
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 2025-07-10
E · Potential for more than minimal harm
2025-06-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-09
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 2025-07-10
E · Potential for more than minimal harm
2025-06-09
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
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 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
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 2025-07-10
D · Potential for more than minimal harm
2025-06-09
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 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
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 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-09
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 2025-07-10
D · Potential for more than minimal harm
2025-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-05-15
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 2025-06-11
G · Actual harm
2025-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-27
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 2025-04-15
E · Potential for more than minimal harm
2025-03-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-04
G · Actual harm
2025-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-14
E · 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 2025-03-14
J · Immediate jeopardy
2024-12-17
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 2025-01-06
D · Potential for more than minimal harm
2024-11-07
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 2024-12-06
D · Potential for more than minimal harm
2024-09-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-05-24
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 2024-06-26
D · Potential for more than minimal harm
2024-05-24
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-06-26
E · Potential for more than minimal harm
2024-05-10
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-10
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 2024-06-14
E · Potential for more than minimal harm
2024-05-10
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 2024-06-14
E · Potential for more than minimal harm
2024-05-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-10
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 2024-06-14
D · Potential for more than minimal harm
2024-05-10
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-10
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 2024-06-14
D · Potential for more than minimal harm
2024-05-10
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 2024-06-14
D · Potential for more than minimal harm
2024-05-10
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 2024-06-14
D · Potential for more than minimal harm
2024-05-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-10
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 2024-06-14
D · Potential for more than minimal harm
2024-05-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-10
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 2024-06-14
D · Potential for more than minimal harm
2024-05-10
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-01-22
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-08-25
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-06-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-06-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-06-09
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 2023-07-10
E · Potential for more than minimal harm
2023-06-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-06-09
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 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
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 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-09
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 2023-07-10
D · Potential for more than minimal harm
2023-06-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-10
G · Actual harm
2023-06-08
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 2023-07-10
D · Potential for more than minimal harm
2023-06-08
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 2023-07-10
D · Potential for more than minimal harm
2023-04-28
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 2023-05-29
D · Potential for more than minimal harm
2023-04-28
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 2023-05-29
D · Potential for more than minimal harm
2023-04-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-05-29
Penalties and ownership
What sits behind the stars
$75,361
2025-02-21
Fine
Fine · fine $75,361
Fine
$46,127
2024-11-07
Fine
Fine · fine $46,127
Fine
$17,160
2023-04-28
Fine
Fine · fine $17,160
Fine
Ownership
Kh7 Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
2430 N 13thpropco LLC
5% Or Greater Mortgage Interest · Organization
Askren, Ann
Operational/Managerial Control · Individual
Erickson, Rachel
Operational/Managerial Control · Individual
Kh7 Hh Cdw
5% Or Greater Indirect Ownership Interest · Organization
Kh7 Ops LLC
5% Or Greater Indirect Ownership Interest · Organization
Loucks, Anne
Operational/Managerial Control · Individual
Oscherowitz, Raphael
5% Or Greater Indirect Ownership Interest · Individual
Oscherowitz, Raphael
Operational/Managerial Control · Individual
Oscherowitz, Raphael
Corporate Officer · Individual
Wolmark, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Wolmark, Chaim
Operational/Managerial Control · Individual
Wolmark, Chaim
Corporate Officer · Individual
Wolmark, Chaim
5% Or Greater Mortgage Interest · Individual
Nearby options
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#3
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4-star overall rating with 3-star inspections with $8,278 in total fines with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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