Cycle 1
Health 2024-12-17 · Fire 2024-12-17
39 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Spokane, WA
Spokane Falls Care
1-star overall rating with 1-star inspections with $184,090 in total fines with 39 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
6021 North Lidgerwood, Spokane, WA
(509) 489-3323
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caldera Care
Operator or chain grouping
Approved since
1967-01-01
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
0.43
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,943
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.75
Baseline 17.65% · Performance 20.62% · Measure score 1.75 · Achievement 1.75 · Improvement 0
Healthcare-associated infections
2.62
Baseline 8.57% · Performance 7.46% · Measure score 2.62 · Achievement 1.27 · Improvement 2.62
Total nurse turnover
0
Baseline 63.64% · Performance 76.74% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.04
Baseline 3.67 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 0.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.05% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 6.75% |
| Discharge to community | 55.02% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 42.86% · Lower 95% interval 38.78% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 57 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 39.29% |
53.69%
14.4 pts worse
|
Numerator 11 · Denominator 28 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 15 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 57 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 12.07% |
8.2%
3.9 pts better
|
Numerator 14 · Denominator 116 |
| Staff flu vaccination coverage | 84.54% |
42%
42.5 pts better
|
Numerator 175 · Denominator 207 |
| Discharge function score | 53.57% |
56.45%
2.9 pts worse
|
Numerator 15 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 6 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
96.0%
0.5 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.6% · Q4 90.0% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
93.8%
4.7 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
2.6%
0.5 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.6% · Q3 0.0% · Q4 1.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.3% |
16.3%
5 pts better
|
11.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 16.7% · Q3 20.4% · Q4 7.3% · 4Q avg 11.3% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.8%
4.8 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
12.1%
0.2 pts worse
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 5.9% · Q3 11.1% · Q4 20.7% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.1% |
15.9%
13.2 pts worse
|
16.7%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 31.8% · Q3 25.6% · Q4 27.1% · 4Q avg 29.1% · 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 | 9.5% |
20.0%
10.5 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.7% · Q3 4.0% · Q4 19.3% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
15.8%
7.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.0% · Q3 3.7% · Q4 15.8% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.2%
0.5 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
23.5%
0.2 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 28.0% · Q3 21.2% · Q4 26.0% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.7%
0.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 7.6% · Q4 6.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
87.7%
4.6 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 99.0% · Q3 98.1% · Q4 75.9% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
13.2%
1.1 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 13.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.4%
2.7 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.6% · Q3 6.0% · Q4 5.2% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
82.0%
15.1 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.2% |
19.9%
11.3 pts worse
|
23.9%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.2% · Observed 33.3% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
33 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2020-02-28 · Fire 2020-02-28
35 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
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 2025-01-15
D · Potential for more than minimal harm
2024-12-17
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-15
F · Potential for more than minimal harm
2023-08-03
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-04
F · Potential for more than minimal harm
2023-08-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-04
D · Potential for more than minimal harm
2023-08-03
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-04
D · Potential for more than minimal harm
2023-08-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-04
F · Potential for more than minimal harm
2020-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-19
E · Potential for more than minimal harm
2020-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-02-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-02-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-05
C · Minimal harm
2020-02-28
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2020-03-04
C · Minimal harm
2020-02-28
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2020-03-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
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 2025-11-27
F · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-05-13
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 2025-06-10
D · Potential for more than minimal harm
2025-05-13
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 2025-06-10
E · Potential for more than minimal harm
2025-04-01
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 2025-05-08
D · Potential for more than minimal harm
2025-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-08
F · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
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 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
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 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-17
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-01-22
D · Potential for more than minimal harm
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
D · Potential for more than minimal harm
2024-12-17
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-17
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 2025-01-22
E · Potential for more than minimal harm
2024-11-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-15
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 2024-11-29
D · Potential for more than minimal harm
2024-11-15
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 2024-11-29
D · Potential for more than minimal harm
2024-11-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-09-25
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 2024-11-08
E · Potential for more than minimal harm
2024-09-25
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 2024-11-08
E · Potential for more than minimal harm
2024-09-25
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 2024-11-08
E · Potential for more than minimal harm
2024-09-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-25
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-04-16
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 2024-05-02
E · Potential for more than minimal harm
2024-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-02
G · Actual harm
2024-03-08
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 2024-02-20
E · Potential for more than minimal harm
2024-03-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-12-06
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-28
G · Actual harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-29
G · Actual harm
2023-11-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-09-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-15
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 2023-10-04
D · Potential for more than minimal harm
2023-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-03
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-03
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 2023-09-13
E · Potential for more than minimal harm
2023-08-03
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 2023-09-13
E · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
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 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-07-18
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 2023-08-04
G · Actual harm
2023-05-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-21
G · Actual harm
2023-04-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-20
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 2023-05-26
D · Potential for more than minimal harm
2023-04-20
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 2023-05-26
D · Potential for more than minimal harm
2023-04-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-05-26
G · Actual harm
2020-02-28
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 2020-04-09
F · Potential for more than minimal harm
2020-02-28
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 2020-04-09
E · Potential for more than minimal harm
2020-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-28
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 2020-04-09
Penalties and ownership
What sits behind the stars
$14,050
2024-03-08
Fine
Fine · fine $14,050
Fine
$111,686
2023-11-02
Fine
Fine · fine $111,686
Fine
$58,354
2023-04-20
Fine
Fine · fine $58,354
Fine
Ownership
Kh7 Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
6021 N Lidgerwood 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
Oscherowitz, Raphael
5% Or Greater Indirect Ownership Interest · Individual
Oscherowitz, Raphael
Operational/Managerial Control · Individual
Oscherowitz, Raphael
Corporate Officer · Individual
Scroggin, Mark
Operational/Managerial Control · Individual
Stuitje, Aletta
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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#3
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4-star overall rating with 3-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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