Cycle 1
Health 2025-03-18 · Fire 2025-03-18
29 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Federal Way, WA
Life Care Center Of Federal Way
2-star overall rating with 2-star inspections with $98,970 in total fines with 29 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1045 South 308th Street, Federal Way, WA
(253) 946-2273
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
157
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1968-09-17
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
0.63
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,650
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.61% · Performance 21.71% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.15% · Performance 8.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Baseline 63.74% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 3.03
Adjusted total nurse staffing
3.01
Baseline 3.91 hours · Performance 3.93 hours · Measure score 3.01 · Achievement 3.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 6.66% |
| Discharge to community | 47.91% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 40.68% · Lower 95% interval 35.15% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.04% |
95.27%
2.8 pts better
|
Numerator 50 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 61.76% |
53.69%
8.1 pts better
|
Numerator 21 · Denominator 34 |
| Discharge mobility score | 41.18% |
50.94%
9.8 pts worse
|
Numerator 14 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 51 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 6.54% |
8.2%
1.7 pts worse
|
Numerator 10 · Denominator 153 |
| Staff flu vaccination coverage | 21.09% |
42%
20.9 pts worse
|
Numerator 31 · Denominator 147 |
| Discharge function score | 58.82% |
56.45%
2.4 pts better
|
Numerator 20 · Denominator 34 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 4 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.4
1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 4.0 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| 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 86.6% · Q2 82.7% · Q3 85.1% · Q4 100.0% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
93.8%
12.8 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.7% · Q3 0.0% · Q4 1.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
16.3%
13.9 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.1% · Q3 2.9% · Q4 0.0% · 4Q avg 2.4% |
| 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 1.7% · Q2 4.5% · Q3 7.9% · Q4 9.1% · 4Q avg 5.9% |
| 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 5.0% · Q2 7.5% · Q3 6.3% · Q4 7.6% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.6% |
15.9%
0.7 pts worse
|
16.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 19.3% · Q3 13.2% · Q4 15.4% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.5% |
20.0%
7.5 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.2% · Q4 8.9% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
15.8%
10.2 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 3.3% · Q3 0.0% · Q4 8.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
1.2%
0.8 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.2% · Q3 2.1% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.7% · Q3 1.4% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
23.5%
7.8 pts better
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 20.0% · Q3 11.5% · Q4 14.1% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.7%
1.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.2% · Q3 2.8% · Q4 3.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
87.7%
7.3 pts worse
|
81.7%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.0% · Q2 78.0% · Q3 78.1% · Q4 88.3% · 4Q avg 80.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
13.2%
8.6 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 5.0% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.4%
1.7 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.5% · Q3 3.1% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.5% |
82.0%
12.5 pts worse
|
79.7%
10.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
19.9%
3.2 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 27.5% · Expected 28.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
36 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-18
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-18
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-18
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 2025-04-02
F · Potential for more than minimal harm
2025-03-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-02
E · Potential for more than minimal harm
2025-03-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-18
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-01-10
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-01-24
F · Potential for more than minimal harm
2024-01-10
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-24
F · Potential for more than minimal harm
2022-09-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-09-30
E · Potential for more than minimal harm
2022-09-15
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2022-09-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-18
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 2025-04-25
E · Potential for more than minimal harm
2025-03-18
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 2025-04-25
E · Potential for more than minimal harm
2025-03-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-18
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 2025-04-25
E · Potential for more than minimal harm
2025-03-18
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 2025-04-25
E · Potential for more than minimal harm
2025-03-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-18
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
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 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-18
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-25
G · Actual harm
2024-12-31
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 2025-01-30
E · Potential for more than minimal harm
2024-12-31
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-01-30
E · Potential for more than minimal harm
2024-12-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-30
E · Potential for more than minimal harm
2024-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-02
G · Actual harm
2024-09-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-29
G · Actual harm
2024-09-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
G · Actual harm
2024-04-03
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 2024-04-26
D · Potential for more than minimal harm
2024-04-03
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 2024-04-26
D · Potential for more than minimal harm
2024-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-26
G · Actual harm
2024-01-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-10
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 2024-02-23
E · Potential for more than minimal harm
2024-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
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 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-13
E · Potential for more than minimal harm
2022-09-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-15
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-15
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-15
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 2022-10-28
D · Potential for more than minimal harm
2022-09-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-15
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 2022-10-28
D · Potential for more than minimal harm
2022-09-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-15
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 2022-10-28
D · Potential for more than minimal harm
2022-09-15
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 2022-10-28
D · Potential for more than minimal harm
2022-09-15
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 2022-10-28
Penalties and ownership
What sits behind the stars
$44,272
2024-04-03
Fine
Fine · fine $44,272
Fine
$54,698
2024-01-10
Fine
Fine · fine $54,698
Fine
Ownership
Preston, Forrest
5% Or Greater Indirect Ownership Interest · Individual
Fund I Investments Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Crhc LLC
General Partnership Interest · Organization
Cross, Cindy
Corporate Officer · Individual
Developers Investment Company Inc
Limited Partnership Interest · Organization
Fund I Investments Limited Partnership
Limited Partnership Interest · Organization
Hcf Inc
Limited Partnership Interest · Organization
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Thurmond, Joan
Corporate Officer · Individual
Zwicker, Tom
W-2 Managing Employee · Individual
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