Cycle 1
Health 2025-05-15 · Fire 2025-05-15
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Reno, NV
Alta Skilled Nursing And Rehabilitation Center
2-star overall rating with 3-star inspections with $39,166 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
555 Hammill Lane, Reno, NV
(775) 828-5600
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
158
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-09-18
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
0.46
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,769
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.04% · Performance 25.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.14
Baseline 6.83% · Performance 7.50% · Measure score 1.14 · Achievement 1.14 · Improvement 0
Total nurse turnover
4.11
Baseline 55.40% · Performance 46.88% · Measure score 4.11 · Achievement 4.11 · Improvement 2.29
Adjusted total nurse staffing
0.90
Baseline 3.29 hours · Performance 3.33 hours · Measure score 0.90 · Achievement 0.90 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 258 · Observed rate 7.75% · Lower 95% interval 6.93% |
| Discharge to community | 51.58% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 315 · Observed rate 46.03% · Lower 95% interval 46.6% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.71% |
95.27%
1.4 pts better
|
Numerator 206 · Denominator 213 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 213 |
| Discharge self-care score | 61.83% |
53.69%
8.1 pts better
|
Numerator 81 · Denominator 131 |
| Discharge mobility score | 58.02% |
50.94%
7.1 pts better
|
Numerator 76 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 2.82% |
2.29%
0.5 pts worse
|
Numerator 6 · Denominator 213 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 7.49% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 193 · Observed rate 7.25% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 16.4% |
8.2%
8.2 pts better
|
Numerator 31 · Denominator 189 |
| Staff flu vaccination coverage | 51.79% |
42%
9.8 pts better
|
Numerator 101 · Denominator 195 |
| Discharge function score | 58.02% |
56.45%
1.6 pts better
|
Numerator 76 · Denominator 131 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 58 · Denominator 60 |
| Transfer of health information to patient | 86.96% |
96.28%
9.3 pts worse
|
Numerator 100 · Denominator 115 |
| Resident COVID-19 vaccinations up to date | 10.99% |
25.2%
14.2 pts worse
|
Numerator 10 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
91.5%
6.3 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 94.4% · Q3 99.2% · Q4 99.2% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
89.6%
9.6 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
2.3%
0.9 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.0% · Q3 4.2% · Q4 3.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
4.9%
0.9 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 1.1% · Q4 2.7% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.6%
1.1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.3% · Q3 1.9% · Q4 5.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
22.2%
1.1 pts better
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 22.6% · Q3 19.1% · Q4 22.9% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
18.5%
4.8 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 14.5% · Q3 14.5% · Q4 14.3% · 4Q avg 13.7% · 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 | 37.2% |
19.1%
18.1 pts worse
|
16.3%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.3% · Q2 35.9% · Q3 33.6% · Q4 30.6% · 4Q avg 37.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
14.2%
10.9 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 34.9% · Q3 21.5% · Q4 18.7% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.8%
0.3 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.9% · Q3 0.0% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.8%
1.3 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.8% · Q3 2.6% · Q4 1.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
16.5%
2.5 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.3% · Q3 18.2% · Q4 18.4% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.5%
1.1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.2% · Q3 2.6% · Q4 6.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
84.1%
14.4 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.8% · Q3 98.0% · Q4 98.3% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.9% |
9.8%
10.1 pts worse
|
12.0%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 21.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.6%
0.3 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.2% · Q3 2.0% · Q4 0.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
80.7%
13.5 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
23.4%
5.7 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 27.9% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
22 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-07-24 · Fire 2023-07-24
29 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
23 fire-safety deficiencies
Top issue: Smoke (12 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-06
E · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-12
E · Potential for more than minimal harm
2023-07-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-24
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 2023-10-20
E · Potential for more than minimal harm
2023-07-24
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-07-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-07-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-07-24
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-07-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-07-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-07-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-07-24
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 2023-10-09
D · Potential for more than minimal harm
2023-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-24
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
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 2025-06-06
D · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-02-24
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 2025-03-14
E · Potential for more than minimal harm
2024-06-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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.
Not marked corrected
D · Potential for more than minimal harm
2024-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-05
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 2024-04-24
D · Potential for more than minimal harm
2024-04-05
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 2024-04-24
D · Potential for more than minimal harm
2024-04-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-04-05
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 2024-04-24
D · Potential for more than minimal harm
2024-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-04-05
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 2024-04-24
D · Potential for more than minimal harm
2024-04-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-04-05
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 2024-04-24
D · Potential for more than minimal harm
2023-12-06
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 2023-12-06
D · Potential for more than minimal harm
2023-12-06
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 2024-01-02
D · Potential for more than minimal harm
2023-12-06
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 2024-01-02
G · Actual harm
2023-07-24
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 2023-08-23
F · Potential for more than minimal harm
2023-07-24
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 2023-09-07
F · Potential for more than minimal harm
2023-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-07-24
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
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 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-24
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-05-31
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 2023-06-26
D · Potential for more than minimal harm
2023-05-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-31
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 2023-06-26
D · Potential for more than minimal harm
2023-05-31
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 2023-06-26
D · Potential for more than minimal harm
2023-05-31
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 2023-06-26
Penalties and ownership
What sits behind the stars
$39,166
2023-07-24
Fine
Fine · fine $39,166
Fine
Ownership
Gray, Zachary
5% Or Greater Direct Ownership Interest · Individual
Gray, Chelsey
Operational/Managerial Control · Individual
Gray, Chelsey
Corporate Officer · Individual
Gray, Zachary
Operational/Managerial Control · Individual
Gray, Zachary
Corporate Director · Individual
Gray, Zachary
Corporate Officer · Individual
Magbitang, Jason
Operational/Managerial Control · Individual
Magboo, Mel
Operational/Managerial Control · Individual
Nadora, Marie
Operational/Managerial Control · Individual
Nasrawy, Joseph
Operational/Managerial Control · Individual
Revive Health Senior Care Management LLC
Operational/Managerial Control · Organization
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