Cycle 1
Health 2025-11-18 · Fire 2025-11-18
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Centralia, WA
Three Rivers Care
5-star overall rating with 5-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1305 Alexander St, Centralia, WA
(360) 754-9792
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caldera Care
Operator or chain grouping
Approved since
2025-01-15
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
0.74
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · Newly certified or not enough cases to report. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
16.3%
13.6 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 13.9% |
5.8%
8.1 pts worse
|
5.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
12.1%
4 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
15.9%
4.1 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
15.8%
6.1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
1.2%
2.7 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.6% |
23.5%
19.9 pts better
|
19.8%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.7%
1.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
87.7%
9.8 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · Q4 95.0% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
13.2%
4.8 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 16.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.4%
1.1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 4.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.0%
18 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.2% |
19.9%
12.3 pts worse
|
23.9%
8.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.2% · Observed 32.4% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-10 · Fire 2024-12-10
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-11-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-03
F · Potential for more than minimal harm
2024-12-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-12-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
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 2025-12-10
D · Potential for more than minimal harm
2025-11-18
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 2025-12-10
D · Potential for more than minimal harm
2025-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-18
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 2025-12-10
D · Potential for more than minimal harm
2025-11-18
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 2025-12-10
D · Potential for more than minimal harm
2025-11-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-18
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 2025-12-10
D · Potential for more than minimal harm
2025-08-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-09-02
Penalties and ownership
What sits behind the stars
Ownership
Kh7 Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
1305 Alexander Propco, LLC
5% Or Greater Mortgage Interest · Organization
Hogue, Ashley
Operational/Managerial Control · Individual
Kh7 Hh Cdw
5% Or Greater Indirect Ownership Interest · Organization
Kh7 Ops LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcdaniel, Pauline
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
Nearby options
Other facilities in reach
#1
South Creek Post Acute
Centralia, WA
4-star overall rating with 3-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Sharon Care Center
Centralia, WA
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Lacey Post Acute & Rehabilitation
Lacey, WA
5-star overall rating with 4-star inspections with $7,443 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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