Cycle 1
Health 2025-05-21 · Fire 2025-05-21
14 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Xenia, OH
Alpine Nursing and Rehabilitation Center
2-star overall rating with 2-star inspections with $27,706 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
164 Office Park Drive, Xenia, OH
(937) 419-4500
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-08-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.42
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,951
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.05
Baseline 73.24% · Performance 56.06% · Measure score 3.05 · Achievement 1.86 · Improvement 3.05
Adjusted total nurse staffing
1.34
Baseline 2.28 hours · Performance 2.93 hours · Measure score 1.34 · Achievement 0 · Improvement 1.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 6.48% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.51% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 114 |
| 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 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.8% |
92.4%
13.6 pts worse
|
93.4%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.3% · Q2 75.8% · Q3 84.3% · Q4 84.4% · 4Q avg 78.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.3% |
94.5%
0.2 pts worse
|
95.5%
1.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.1% · Q3 4.3% · Q4 3.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 61.8% |
26.1%
35.7 pts worse
|
11.4%
50.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.6% · Q2 53.4% · Q3 71.2% · Q4 62.5% · 4Q avg 61.8% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
6.2%
3.8 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 10.9% · Q3 9.1% · Q4 5.7% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
25.4%
2.4 pts better
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 26.1% · Q3 21.8% · Q4 20.8% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
11.5%
4.1 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.1% · Q3 6.2% · Q4 8.6% · 4Q avg 7.4% · 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 | 7.0% |
7.7%
0.7 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 8.9% · Q3 13.5% · Q4 0.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
6.2%
0.2 pts worse
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.4% · Q3 7.8% · Q4 6.1% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
21.7%
6.2 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 13.4% · Q3 20.3% · Q4 20.7% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.7%
1.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.6% · Q3 3.0% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 40.6% |
78.1%
37.5 pts worse
|
81.7%
41.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.2% · Q2 42.6% · Q3 25.8% · Q4 32.1% · 4Q avg 40.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.4% |
75.6%
15.2 pts worse
|
79.7%
19.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-29 · Fire 2022-08-29
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-08-28 · Fire 2019-08-28
28 health deficiencies
Top issue: Resident Rights (7 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-21
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-06-13
F · Potential for more than minimal harm
2022-08-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-08-29
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 2022-10-24
F · Potential for more than minimal harm
2022-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-08-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-08-29
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 2022-10-24
E · Potential for more than minimal harm
2022-08-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-24
F · Potential for more than minimal harm
2019-08-28
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-12-19
F · Potential for more than minimal harm
2019-08-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-28
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 2019-12-19
F · Potential for more than minimal harm
2019-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-09
E · Potential for more than minimal harm
2019-08-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-09
E · Potential for more than minimal harm
2019-08-28
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 2019-12-09
E · Potential for more than minimal harm
2019-08-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-09
E · Potential for more than minimal harm
2019-08-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-19
E · Potential for more than minimal harm
2019-08-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-12-09
E · Potential for more than minimal harm
2019-08-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-12-19
E · Potential for more than minimal harm
2019-08-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-09
E · Potential for more than minimal harm
2019-08-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
F · Potential for more than minimal harm
2025-05-21
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 2025-06-13
E · Potential for more than minimal harm
2025-05-21
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 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
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 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-13
G · Actual harm
2025-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-02
G · Actual harm
2025-04-08
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 2025-04-28
D · Potential for more than minimal harm
2025-04-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-28
D · Potential for more than minimal harm
2024-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-29
C · Minimal harm
2024-11-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-05-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-02-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-06-13
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 2023-06-23
D · Potential for more than minimal harm
2023-06-13
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 2023-06-23
F · Potential for more than minimal harm
2022-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-08-29
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 2022-10-24
D · Potential for more than minimal harm
2022-08-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-08-29
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 2022-10-24
D · Potential for more than minimal harm
2022-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-08-29
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 2022-10-24
F · Potential for more than minimal harm
2019-08-28
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 2019-12-09
F · Potential for more than minimal harm
2019-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-12-09
E · Potential for more than minimal harm
2019-08-28
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 2019-12-09
E · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
D · Potential for more than minimal harm
2019-08-28
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 2019-12-09
Penalties and ownership
What sits behind the stars
$27,706
2025-04-08
Fine
Fine · fine $27,706
Fine
Ownership
Aaa Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Aaa Eminent LLC
5% Or Greater Indirect Ownership Interest · Organization
Aaa Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ausch, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Ausch, Chaim
Operational/Managerial Control · Individual
Eminent Care Group LLC
Operational/Managerial Control · Organization
Geldzahler, Yaakov
5% Or Greater Indirect Ownership Interest · Individual
Geldzahler, Yaakov
Operational/Managerial Control · Individual
Mack, Lauren
Operational/Managerial Control · Individual
S & T Bank
5% Or Greater Mortgage Interest · Organization
Smith, Jazmaine
Operational/Managerial Control · Individual
Zserebrowski, Yechezkel
Operational/Managerial Control · Individual
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#3
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