Special Focus Facility (“SFF”) Program

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop C2-21-16 Baltimore, Maryland 21244-1850

Center for Clinical Standards and Quality/Quality Safety & Oversight Group

Special Focus Facility (SFF) Program

This webpage offers a list of nursing homes that have a history of serious quality issues and are included in a special program to stimulate improvements in their quality of care. Please take a minute to review this background information on our Special Focus Facility (SFF) program. The background here will help you be as informed as possible when you discuss your long-term care options with any nursing home that is listed here ? and what they are doing to improve their quality of care.

Background The Centers for Medicare & Medicaid Services (CMS) and State Agencies (SAs) inspect nursing homes on a regular basis to determine if they are providing the quality of care that Medicare and Medicaid require in order to protect and improve residents' health and safety. When nursing homes do not meet CMS' health care or fire safety standards, these instances are cited as deficiencies, and we require that the problems be corrected.

Most nursing homes have some deficiencies, with the average being six to seven deficiencies per standard health inspection. However, we have found that a minority of nursing homes have:

? More problems than other nursing homes (about twice the average number of deficiencies),

? More serious problems than most other nursing homes (including harm or injury experienced by residents), and

? A pattern of serious problems that have persisted over a long period of time (as measured over approximately three years before the date the nursing home was first put on the SFF list).

Although such nursing homes may periodically institute enough improvements to correct problems identified on one inspection, significant problems would often re-surface by the time of the next inspection. Such facilities with a "yo-yo" compliance history rarely address underlying systemic problems that give rise to repeated cycles of serious deficiencies, which pose risks to residents' health and safety. To address this problem CMS operates the SFF program.

How the SFF Program Works The methodology for identifying facilities for the SFF program is based on the same methodology used in the health inspection domain of the Five-Star Quality Rating System. Results from the last three standard health survey cycles and the last three years of complaint survey performance are converted into points based on the number of deficiencies cited, and the scope and severity (S/S) level of those citations. The more deficiencies that are cited, and the more cited at higher levels of S/S, the more points are assigned. More information about this methodology can be found at Enrollment-andCertification/CertificationandComplianc/downloads/usersguide.pdf.

The facilities with the most points in a state then become candidates for the SFF program. The number of nursing homes on the candidate list is based on five candidates for each SFF slot, with a minimum candidate pool of five nursing homes and a maximum of 30 per State. SAs use this list to select nursing homes to fill the SFF slot(s) in their state. Additionally, since a facility's staffing (staffing levels and turnover) is very important to residents' care, CMS recommends that SAs consider a facility's staffing information when selecting SFFs from the SFF candidate list. See the list of candidates in Table D below.

Once a state selects a facility as an SFF, the SA, on CMS's behalf, conducts a full, onsite inspection of all Medicare health and safety requirements every six months, and recommends progressive enforcement (e.g., civil money penalty, denial of Medicare payment, etc.) until the nursing home either (1) graduates from the SFF program; or (2) is terminated from the Medicare and/or Medicaid program(s). While in the SFF program, CMS expects facilities to take meaningful actions to address the underlying and systemic issues leading to poor quality.

Once an SFF graduates or is terminated, each SA then selects a new SFF from a monthly list of candidates. CMS also informs candidate nursing homes of their inclusion on the SFF candidate list in the monthly preview of the Five-Star Quality Rating System. The facility will graduate from the SFF program once it has had two consecutive standard health surveys with 12 or fewer deficiencies cited at S/S of "E" or less on each survey (these surveys must have occurred after the facility has been selected as an SFF). To avoid situations where a facility remains an SFF for a prolonged period of time, CMS is establishing criteria that could result in the facility's termination from the Medicare and/or Medicaid programs. SFFs with deficiencies cited at Immediate Jeopardy on any two surveys while in the SFF program, will be considered for discretionary termination.

For more information on the SFF program, please see CMS memorandum QSO-23-01-NH.

How Can You Use This Information? If you are considering admission to a nursing home included on this list you may want to:

? Visit the Care Compare website to view information about the nursing home's star ratings, staffing, quality measures, and inspection results (see ).

? Visit the nursing home. Talk to staff, residents, physicians, and other families. Ask the nursing home staff what they are doing to improve the quality of care for residents in the nursing home.

? Call the SA (agency contact information is posted on Care Compare) to find out more about the nursing home.

? If the nursing home is an SFF, look at the length of time that a nursing home has been on the SFF list. This is particularly important if the nursing home has been an SFF nursing home for more than 18-24 months since such nursing homes are closer to either graduating (due to improvements) or ending their participation in Medicare and Medicaid.

? Call your local State Ombudsman, Administration on Aging, and local groups to find out more about the nursing home.

If you currently reside in an SFF nursing home, please know that this home is being closely monitored and will be inspected twice as often as other nursing homes. You may also direct any questions you have to the contacts above.

How to Interpret the Tables Below we list nursing homes in four (4) different categories:

Table A ? Current SFF Facilities: Nursing homes that are currently in the SFF program. The date of the most recent inspection is posted. Results of the most recent inspection are noted as met or not met. "Met" means the SFF facility met the graduation criteria on their most recent survey and is on track for graduation. SFF facilities must meet the graduation criteria on 2 consecutive surveys in order to be eligible for graduation. "Not met" means the SFF facility did not meet the graduation criteria on their most recent survey and must restart the process towards graduation.

Table B ? Facilities That Have Graduated from the SFF Program: These nursing homes sustained improvement for about 12 months (through two standard health surveys) while in the SFF program. CMS lists their names as "graduates" for three years after they graduate so that anyone who has been tracking their progress will be informed. "Graduation" does not mean that there may not be problems in the quality of care but does generally indicate an upward trend in quality improvement compared to the nursing home's prior history of care.

Table C ? No Longer in Medicare and Medicaid: These are nursing homes that were either terminated by CMS from participation in Medicare and Medicaid within the past few months or voluntarily chose not to continue such participation. In most cases, the nursing homes will have closed, although some nursing homes that leave Medicare later seek to show better quality and re-enter the Medicare program after demonstrating their ability to comply with all Federal health and safety requirements.

Table D ? SFF Candidate list: These are nursing homes that qualify to be selected as an SFF. The number of nursing homes on the candidate list is based on five candidates for each SFF slot, with a minimum candidate pool of five nursing homes and a maximum of 30 per State.

Important Note about Information Delays The SAs are responsible for entering survey information into CMS' databases and providing updates as needed. Every attempt is made to assure the accuracy and timeliness of the information on the list. However, data lags can occur between the completion of an inspection and the posting of information on this list. We advise interpreting this information cautiously and supplementing it with information from the ombudsman's office, the SA, or other sources.

Table A: Current SFF Facilities

Provider

Phone

Most Recent Met Survey Months as an

Number Facility Name

Address

City

State Zip Number

Inspection Criteria

SFF

015217 Birmingham Nursing And Rehabilitation Ctr Llc

1000 Dugan Avenue

Birmingham AL 35214 205-798-8780 01/25/2024 Met

15

045287 Bear Creek Healthcare Llc

322 West Collin Raye Drive

De Queen

AR 71832 870-642-3562

3

035146 Life Care Center Of Paradise Valley

4065 East Bell Road

Phoenix

AZ 85032 602-867-0212 01/18/2024 Met

4

555772 Joshua Tree Post Acute

8515 Cholla Ave

Yucca Valley CA 92284 760-853-4760 10/06/2023 Not Met

17

555565 Artesia Palms Care Center

11900 E. Artesia Blvd.

Artesia

CA 90701 562-865-0271 01/12/2024 Not Met

24

056435 Hyde Park Healthcare Center

6520 West Blvd.

Los Angeles CA 90043 323-753-1354 01/12/2024 Met

28

055412 Orchard Post Acute Care

101 S Orchard Ave

Vacaville

CA 95688 707-448-6458 02/09/2024 Not Met

22

555776 Gridley Post Acute

246 Spruce Street

Gridley

CA 95948 530-846-5671 03/08/2024 Met

23

056078 Alta View Post Acute

831 S Lake Street

Los Angeles CA 90057 213-380-9175 03/21/2024 Met

26

065232 Atlas Post Acute

2611 Jones Ave

Pueblo

CO 81004 719-564-1735 11/02/2023 Not Met

14

075182 Grandview Rehabilitation And Healthcare Center 55 Grand Street

New Britain CT 06052 860-223-3617 11/09/2023 Not Met

21

085012 Regency Healthcare & Rehab Center

801 N. Broom Street

Wilmington DE 19806 302-654-8400 12/15/2023 Not Met

20

105234 Rehabilitation And Healthcare Center Of Tampa

4411 N Habana Ave

Tampa

FL 33614 813-872-2771

0

106074 Aspire At Kissimmee Gardens

1120 W Donegan Ave

Kissimmee

FL 34741 407-847-2854 10/26/2023 Met

19

105407 Siesta Key Health And Rehabilitation Center

4602 Northgate Court

Sarasota

FL 34234 941-355-2913 02/23/2024 Met

4

115561 Meadowbrook Health And Rehab

4608 Lawrenceville Highway

Tucker

GA 30084 770-491-9444

1

115585 Legacy Transitional Care & Rehabilitation

460 Auburn Avenue N.E.

Atlanta

GA 30312 404-523-1613 10/13/2023 Met

9

125056 Hale Makua Health Services

1540 Lower Main Street

Wailuku

HI 96793 808-243-1722 11/08/2023 Met

16

165344 Aspire Of Gowrie

1808 Main Street

Gowrie

IA 50543 515-357-5817 02/06/2024 Not Met

7

165478 Arbor Court

701 East Mapleleaf Drive

Mount Pleasant IA 52641 319-385-1400 02/08/2024 Met

13

135146 Cascadia Of Boise

6000 W Denton St

Boise

ID 83704 208-629-4383 03/22/2024 Met

10

145811 Aperion Care Peoria Heights

1629 East Gardner Lane

Peoria Heights IL 61616 309-685-1545

3

145180 Aperion Care Chicago Heights

490 West 16th Place

Chicago Heights IL 60411 708-481-4444 02/01/2024 Not Met

29

145850 City View Multicare Center

5825 West Cermak Road

Cicero

IL 60804 708-656-9120 02/01/2024 Not Met

9

146097 El Paso Health Care Center

850 East Second Street

El Paso

IL 61738 309-527-2700 02/07/2024 Not Met

10

155156 Aperion Care Arbors Michigan City

1101 E Coolspring Ave

Michigan City IN 46360 219-874-5211

1

155222 Kokomo Healthcare Center

429 W Lincoln Rd

Kokomo

IN 46902 765-453-5600 11/06/2023 Not Met

7

155491 Majestic Care Of Connersville

1029 E 5th Street

Connersville IN 47331 765-825-0543 02/12/2024 Met

10

175450 Anew Healthcare Oxford

200 S Ohio St

Oxford

KS 67119 620-455-2214

1

175172 Topeka Center For Rehabilitation And Healthcare 2515 Sw Wanamaker Road

Topeka

KS 66614 785-271-6808 11/30/2023 Not Met

13

185262 Madison Health And Rehabilitation Center

131 Meadowlark Drive

Richmond

KY 40475 859-623-3564 11/17/2023 Not Met

13

195177 Lakeshore Manor Nursing & Rehab

1400 Lindberg Drive

Slidell

LA 70458 985-641-4985 01/11/2024 Not Met

5

225747 Somerset Ridge Center

455 Brayton Avenue

Somerset

MA 02726 508-679-2240 01/10/2024 Not Met

15

225488 Tremont Health Care Center

605 Main Street

Wareham

MA 02571 508-295-1040 03/05/2024 Not Met

4

215094 Westminster Healthcare Center

1234 Washington Road

Westminster MD 21157 410-848-0700 09/21/2023 Not Met

8

235187 Mission Point Nsg Phy Rehab Ctr Of Madison Heights 31155 Dequindre

Madison Heights MI 48071 248-940-5390

1

235532 Ashley Healthcare Center

103 West Wallace Street

Ashley

MI 48806 989-847-2011 04/01/2024 Not Met

11

245052 Moorhead Rehabilitation & Healthcare Center

2810 Second Avenue North

Moorhead

MN 56560 218-233-7578 10/19/2023 Not Met

55

245544 Victory Health & Rehabilitation Center

512 49th Avenue North

Minneapolis MN 55430 612-529-7747 12/21/2023 Not Met

49

265857 Liberty Health And Wellness

2201 Glenn Hendren Dr

Liberty

MO 64068 816-736-8800 10/16/2023 Met

24

265379 Riverside Nursing & Rehabilitation Center, Llc

4700 Nw Cliffview Drive

Riverside

MO 64150 816-741-5105 11/20/2023 Not Met

33

265469 Levering Regional Health Care Center

1734 Market Street

Hannibal

MO 63401 573-221-2930 01/24/2024 Not Met

17

255112 Pleasant Hills Community Living Center

1600 Raymond Rd

Jackson

MS 39204 601-371-1700 02/14/2024 Not Met

35

275026 Ivy At Great Falls

1130 17th Ave S

Great Falls

MT 59405 406-771-4500 10/12/2023 Not Met

23

345420 Alamance Health Care Center

1987 Hilton Road

Burlington

NC 27217 336-226-0848 11/02/2023 Met

19

345008 The Citadel At Myers Park, Llc

300 Providence Road

Charlotte

NC 28207 704-334-1671 02/22/2024 Not Met

3

355093 Good Samaritan Society - Bottineau

725 E 10th St

Bottineau

ND 58318 701-228-3796

0

285239 Emerald Nursing & Rehab Legacy Pointe

3110 Scott Circle

Omaha

NE 68112 402-455-6636 11/30/2023 Not Met

18

305051 Keene Center, Genesis Healthcare

677 Court Street

Keene

NH 03431 603-357-3800 11/16/2023 Met

7

315280 Silver Healthcare Center

1417 Brace Road

Cherry Hill

NJ 08034 856-795-3131 12/12/2023 Not Met

18

315390 Cranford Park Care

600 Lincoln Park East

Cranford

NJ 07016 908-276-7100 03/27/2024 Not Met

14

Updated April 24, 2024

1

Provider Number Facility Name

325131 295000 335338 335744 335082 365826 365952 365754 366150 375543 375568 385091 395414 395421 395929 395397 415084 425302 435129 445339 445387 675371 455565 675459 676132 675764 676285 465117 495235 475020 505491 525108 525409 515169 535026

Spanish Trails Rehabilitation Suites Pershing General Hospital Snf Bishop Rehabilitation And Nursing Center Grand Manor Nursing & Rehabilitation Center Waterview Heights Rehabilitation And Nursing Ctr Continuing Healthcare Of Cuyahoga Falls Ridgewood Manor Majestic Care Of Columbus Llc Astoria Place Of Cincinnati Mooreland Heritage Manor Maplewood Care Center Hearthstone Nursing & Rehabilitation Center Aventura At Terrace View Glen Brook Rehabilitation And Healthcare Center Ridgeview Healthcare & Rehab Center Kingston Rehabilitation And Nursing Center Elmhurst Rehabilitation & Healthcare Center Rehab Center Of Cheraw Dells Nursing And Rehab Center Inc Bailey Park Clc Parkway Health And Rehabilitation Center Riverview Nursing & Rehabilitation Palestine Healthcare Center Oasis At Austin Trail Lake Nursing & Rehabilitation Spring Branch Transitional Care Center Remarkable Healthcare Of Fort Worth South Ogden Post Acute Williamsburg Post Acute & Rehabilitation Berlin Health & Rehab Ctr Everett Center Allis Care Center Pine View Care Center Valley Center Big Horn Rehabilitation And Care Center

Address

Table A: Current SFF Facilities City

Phone State Zip Number

Most Recent Met Survey Months as an

Inspection Criteria

SFF

1610 Renaissance Blvd Ne

Albuquerque NM 87107 505-600-4800 03/22/2024 Not Met

10

855 6th Street

Lovelock

NV 89419 775-273-2621 10/19/2023 Not Met

18

918 James Street

Syracuse

NY 13203 315-474-1561 12/05/2023 Not Met

25

700 White Plains Road

Bronx

NY 10473 718-518-8892 12/22/2023 Not Met

13

425 Beach Avenue

Rochester

NY 14612 585-663-0930 01/25/2024 Not Met

4

300 East Bath Road

Cuyahoga Falls OH 44223 330-929-6272

2

3231 Manley Road

Maumee

OH 43537 419-865-1248 01/25/2024 Not Met

10

44 S Souder Ave

Columbus

OH 43222 614-228-5900 02/22/2024 Not Met

10

3627 Harvey Avenue

Cincinnati

OH 45229 513-961-8881 03/14/2024 Met

12

402 Southeast 6th Street

Mooreland

OK 73852 580-994-5570 01/11/2024 Met

6

6202 East 61st Street

Tulsa

OK 74136 918-494-8830 03/20/2024 Met

8

2901 E. Barnett Road

Medford

OR 97504 541-779-4221

3

108 Terrace Drive

Olyphant

PA 18447 570-489-8611

1

801 East 16th Street

Berwick

PA 18603 570-759-5400 12/08/2023 Not Met

30

200 Pennsylvania Avenue

Shenandoah PA 17976 570-462-1921 01/26/2024 Not Met

18

200 Second Avenue

Kingston

PA 18704 570-288-9315 03/15/2024 Not Met

24

50 Maude Street

Providence

RI 02908 401-456-2600 03/14/2024 Not Met

20

1150 State Road

Cheraw

SC 29520 843-537-2060

2

1400 Thresher Dr

Dell Rapids

SD 57022 605-428-5478 02/12/2024 Not Met

9

2400 Mitchell Street

Humboldt

TN 38343 731-784-5183 11/21/2023 Not Met

58

200 South Parkway West

Memphis

TN 38109 901-942-7456 02/29/2024 Met

8

1102 River Rd

Boerne

TX 78006 830-249-2799

2

1816 Tile Factory Rd

Palestine

TX 75801 903-729-2261

4

3509 Rogge Ln

Austin

TX 78723 512-926-2070

2

7100 Trail Lake Dr

Fort Worth

TX 76133 817-263-2224

1

1615 Hillendahl Rd

Houston

TX 77055 713-365-0561 11/10/2023 Not Met

11

6649 N Riverside Dr

Fort Worth

TX 76137 817-847-1860 11/10/2023 Not Met

15

5540 South 1050 East

Ogden

UT 84405 801-479-8455 03/21/2024 Not Met

11

1235 S Mount Vernon Avenue Williamsburg VA 23185 757-229-4121 10/20/2023 Not Met

33

98 Hospitality Drive

Barre

VT 05641 802-229-0308 03/01/2024 Not Met

6

1919 112th Street Southwest Everett

WA 98204 425-513-1600

0

9047 W Greenfield Ave

West Allis

WI 53214 414-453-9290 12/14/2023 Not Met

34

400 County Rd R

Black River Falls WI 54615 715-284-5396 03/28/2924 Met

50

1000 Lincoln Drive

South Charleston WV 25309 304-768-4400 10/17/2023 Not Met

10

1851 Big Horn Ave

Sheridan

WY 82801 307-674-4416 10/05/2023 Met

9

"Met" means the SFF facility met the graduation criteria on their most recent survey and is on track for graduation. SFF facilities must meet the graduation criteria on 2 consecutive surveys in order to be eligible for graduation. "Not met" means the SFF facility did not meet the graduation criteria on their most recent survey and must restart the process towards graduation. If the most recent inspection and met survey criteria is not listed that means the facility is "New" and the facility is awaiting their first survey. For additional information please see How the SFF Program Works above.

Updated April 24, 2024

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