Nursing Homes with History of Serious Issues

This webpage offers a list of nursing homes that have a history of serious quality issues or are included in a special program to stimulate improvements in their quality of care. Please take a minute to review the background information on the "Special Focus Facility" program below the lists. The background information 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. Many of these nursing homes are also on the NHAA Watchlist and we have included links to get more details about those nursing homes.


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Facilities Newly Added to the SFF Program (List A)

Facilities That Have Not Improved (List B)

Facilities That Have Shown Improvement (List C)

Facilities That Have Recently Graduated from the SFF Program (List D)

  • Brandywine Nursing & Rehabilitation Center – Wilmington, DE
  • Aperion Care Bradley – Bradley, IL
  • Signature Healthcare Of Lafayette – Lafayette, IN
  • Overland Park Rehabilitation And Healthcare – Overland Park, KS
  • Green Park Senior Living Community – Saint Louis, MO
  • Western Horizons Care Center – Hettinger, ND
  • Pleasant Acres Rehabilitation And Nursing Center – York, PA
  • Willow Terrace – Philadelphia, PA
  • White River Health Care Center – White River, SD
  • Colonial Manor Care Center – New Braunfels, TX
  • River City Care Center – San Antonio, TX
  • Windcrest Nursing And Rehabilitation – San Antonio, TX
  • Envoy Of Westover Hills – Richmond, VA
  • Bay At Colonial Manor Health And Rehab (The) – Wausau, WI

Facilities No Longer Participating in the Medicare and Medicaid Program (List E)

Last updated September 29, 2021.


How to Interpret the Lists

Below we list nursing homes in six (6) different categories:

  • List A - New Additions: Nursing homes newly added to the SFF list (which have not yet had a standard inspection survey since being added to the list).
  • List B - Not Improved: Nursing homes that have failed to show significant improvement despite being given the opportunity to show improvement in at least one inspection after being named as a SFF nursing home.
  • List C - Improving: Nursing homes that have shown significant improvement, as indicated by the most recent inspection, and CMS is waiting to see if the improvement continues over time. If the improvement continues for about 12 months (through two standard inspections), these nursing homes will graduate from the SFF program. “Significant improvement” means that the most recent standard inspection (and any complaint investigations) found no deficiencies in which there was actual harm to any resident, and no deficiency in which there was widespread systemic potential for harm (i.e. no deficiency at or above an “F” level).
  • List D - Recently Graduated: These nursing homes not only improved, but they sustained significant improvement for about 12 months (through two standard inspections). CMS lists their names as “graduates” for a few months 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 quality of care, but does generally indicate an upward trend in quality improvement compared to the nursing home’s prior history of care.
  • List E - 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.
  • List F – 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.

Background

The Centers for Medicare & Medicaid Services (CMS) and state agencies inspect nursing homes on a regular basis to determine if they are providing the quality of care that Medicare and Medicaid requires in order to protect and improve residents’ health and safety. These "survey" or "inspection" teams will identify deficiencies in the quality of care that is provided. They also identify any deficiencies in meeting CMS safety requirements (such as protection from fire hazards). 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. If serious problems are not corrected, they may terminate the nursing home's participation in Medicare and Medicaid.

Most nursing homes have some deficiencies, with the average being 6-7 deficiencies per inspection. Many nursing homes correct their problems within a reasonable period of time. 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 has persisted over a long period of time (as measured over the 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” or “in and out” 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 created the “Special Focus Facility” (SFF) program.

How the Special Focus Facility (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 over three cycles (approximately three years) of inspections are converted into points based on the number of deficiencies cited and the scope and severity level of those citations. The more deficiencies that are cited, and the more cited at higher levels of scope and severity, the more points are assigned. More information about this methodology can be found at https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/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. State agencies use this list to select nursing homes to fill the SFF slot(s) in their state. See list of candidates in Table F below.

Once a state selects a facility as an SFF, the State Survey Agency, 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., fines, denial of Medicare payment) until the nursing home either (1) graduates from the SFF program; or (2) is terminated from the Medicare and/or Medicaid program(s).

Once an SFF graduates or is terminated, each State 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.

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 Nursing Home Compare website to view information about the nursing home’s star ratings, staffing, quality measures, and inspection results (see https://www.medicare.gov/nursinghomecompare/search.html).
  • Visit the nursing home. Talk to staff, residents, physicians, and other families. You may request to see the results from the last State or CMS survey (it should be in a place that is easily accessible.)
  • Ask the nursing home staff what they are doing to improve the quality of care for residents in the nursing
  • Call the State survey agency (link to Nursing Home Compare) to find out more about the nursing nome
  • 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 a SFF nursing home, please know that this home is being closely monitored (it is inspected twice as often as other nursing homes). You may also direct any questions you have to the contacts above. The good news is that most of the nursing homes in the SFF program significantly improve their quality of care within 18-24 months after being selected, while about 10% tend to be terminated from Medicare and Medicaid.

Important Note about Information Delays

The State survey agencies 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 of up to several months can occur between completion of an inspection and posting of data on this list. We advise interpreting this information cautiously and supplementing it with information from the ombudsman's office, the State survey agency, or other sources.

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