Fishersville, VA

Augusta Nursing & Rehab Center

1-star overall rating with 1-star inspections with abuse icon flag with $203,292 in total fines with 17 recent health deficiencies

83 Crossroads Lane, Fishersville, VA

(540) 885-8424

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

112

Certified beds

Average residents

83

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care

Operator or chain grouping

Approved since

1999-01-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

36 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.00

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

1.54

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

2.96

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

2.58

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.21

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.38

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

71%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,008

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.30

Composite VBP score used to determine payment impact.

Payment multiplier

0.9883

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.11

Baseline 17.28% · Performance 18.14% · Measure score 7.11 · Achievement 7.11 · Improvement 0

Healthcare-associated infections

3.32

Baseline 5.55% · Performance 6.84% · Measure score 3.32 · Achievement 3.32 · Improvement 0

Total nurse turnover

2.47

Baseline 50.77% · Performance 53.57% · Measure score 2.47 · Achievement 2.47 · Improvement 0

Adjusted total nurse staffing

0.81

Baseline 2.66 hours · Performance 3.07 hours · Measure score 0.81 · Achievement 0 · Improvement 0.81

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.85%
10.72%
0.9 pts better
No Different than the National Rate · Eligible stays 244 · Observed rate 8.2% · Lower 95% interval 6.79%
Discharge to community 52.94%
50.57%
2.4 pts better
No Different than the National Rate · Eligible stays 233 · Observed rate 49.79% · Lower 95% interval 47.16%
Medicare spending per beneficiary 0.87
1.02
0.2 pts better
Drug regimen review with follow-up 96.92%
95.27%
1.7 pts better
Numerator 126 · Denominator 130
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 130
Discharge self-care score 74.12%
53.69%
20.4 pts better
Numerator 63 · Denominator 85
Discharge mobility score 54.12%
50.94%
3.2 pts better
Numerator 46 · Denominator 85
Pressure ulcers or injuries, new or worsened 3.85%
2.29%
1.6 pts worse
Numerator 5 · Denominator 130 · Adjusted rate 5.07%
Healthcare-associated infections requiring hospitalization 6.84%
7.12%
0.3 pts better
No Different than the National Rate · Eligible stays 169 · Observed rate 5.33% · Lower 95% interval 4.5%
Staff COVID-19 vaccination coverage 8.86%
8.2%
0.7 pts better
Numerator 7 · Denominator 79
Staff flu vaccination coverage 24.49%
42%
17.5 pts worse
Numerator 24 · Denominator 98
Discharge function score 60%
56.45%
3.5 pts better
Numerator 51 · Denominator 85
Transfer of health information to provider 97.78%
95.95%
1.8 pts better
Numerator 44 · Denominator 45
Transfer of health information to patient 94.2%
96.28%
2.1 pts worse
Numerator 65 · Denominator 69
Resident COVID-19 vaccinations up to date 2.04%
25.2%
23.2 pts worse
Numerator 1 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.4
1.5
1.1 pts better
1.9
1.5 pts better
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.1
1.4
0.3 pts better
1.8
0.7 pts better
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 83.9%
91.2%
7.3 pts worse
93.4%
9.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 68.4% · Q2 84.7% · Q3 94.1% · Q4 90.9% · 4Q avg 83.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 94.8%
94.0%
0.8 pts better
95.5%
0.7 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8%
Percentage of long-stay residents experiencing one or more falls with major injury 3.9%
3.6%
0.3 pts worse
3.3%
0.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.2% · Q3 4.4% · Q4 3.0% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 3.0%
15.7%
12.7 pts better
11.4%
8.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 0.0% · Q3 1.6% · Q4 4.6% · 4Q avg 3.0%
Percentage of long-stay residents who lose too much weight 7.4%
5.7%
1.7 pts worse
5.4%
2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.5% · Q3 7.7% · Q4 8.5% · 4Q avg 7.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 20.4%
20.2%
0.2 pts worse
19.6%
0.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.7% · Q3 21.2% · Q4 20.6% · 4Q avg 20.4%
Percentage of long-stay residents who received an antipsychotic medication 8.2%
15.0%
6.8 pts better
16.7%
8.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 8.2% · Q3 5.3% · Q4 7.8% · 4Q avg 8.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.2%
0.2 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 25.6%
17.5%
8.1 pts worse
16.3%
9.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 43.2% · 4Q avg 25.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 18.1%
15.7%
2.4 pts worse
14.9%
3.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 24.3% · Q3 23.1% · Q4 14.5% · 4Q avg 18.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.5%
0.5 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 0.0%
1.6%
1.6 pts better
1.7%
1.7 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 new or worsened bowel or bladder incontinence 35.0%
22.2%
12.8 pts worse
19.8%
15.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 38.3% · Q3 32.9% · Q4 38.2% · 4Q avg 35.0%
Percentage of long-stay residents with pressure ulcers 10.1%
5.2%
4.9 pts worse
5.1%
5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 12.2% · Q3 8.5% · Q4 6.8% · 4Q avg 10.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 33.1%
74.6%
41.5 pts worse
81.7%
48.6 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 18.8% · Q3 46.8% · Q4 47.3% · 4Q avg 33.1%
Percentage of short-stay residents who had an outpatient emergency department visit 17.3%
11.7%
5.6 pts worse
12.0%
5.3 pts worse
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.9% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.2%
1.2 pts better
1.6%
1.6 pts better
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 33.1%
73.6%
40.5 pts worse
79.7%
46.6 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 33.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 15.7%
22.0%
6.3 pts better
23.9%
8.2 pts better
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 13.1% · Expected 19.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-02-28 · Fire 2023-02-28

17 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-04-07 · Fire 2022-04-07

50 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-08-29 · Fire 2019-08-29

9 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2019-08-29

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2019-10-22

Inspection history

Recent health citations

K · Immediate jeopardy 2024-10-18

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 2024-12-02

E · Potential for more than minimal harm 2024-10-18

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 2024-12-02

E · Potential for more than minimal harm 2024-10-18

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-12-02

E · Potential for more than minimal harm 2024-10-18

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-12-02

E · Potential for more than minimal harm 2024-10-18

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-12-02

D · Potential for more than minimal harm 2024-10-18

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-12-02

D · Potential for more than minimal harm 2024-10-18

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-10-18

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 2024-12-30

D · Potential for more than minimal harm 2024-10-18

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-02

D · Potential for more than minimal harm 2024-10-18

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 2024-12-02

D · Potential for more than minimal harm 2024-10-18

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 2024-12-02

D · Potential for more than minimal harm 2024-10-18

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-12-02

D · Potential for more than minimal harm 2024-10-18

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-12-02

D · Potential for more than minimal harm 2024-10-18

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 2024-12-02

K · Immediate jeopardy 2024-08-06

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 2024-10-09

K · Immediate jeopardy 2024-08-06

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 2024-10-09

K · Immediate jeopardy 2024-08-06

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-02

K · Immediate jeopardy 2024-08-06

F675 · Quality of Life and Care Deficiencies

Health

Honor each resident's preferences, choices, values and beliefs.

Corrected 2024-10-09

K · Immediate jeopardy 2024-08-06

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 2024-12-02

H · Actual harm 2024-08-06

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-12-02

E · Potential for more than minimal harm 2024-08-06

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 2024-12-02

E · Potential for more than minimal harm 2024-08-06

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-12-02

E · Potential for more than minimal harm 2024-08-06

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-12-02

E · Potential for more than minimal harm 2024-08-06

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-12-02

E · Potential for more than minimal harm 2024-08-06

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 2024-12-02

D · Potential for more than minimal harm 2024-08-06

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-08-06

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-08-06

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 2024-12-02

D · Potential for more than minimal harm 2024-08-06

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 2024-12-02

D · Potential for more than minimal harm 2024-08-06

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-12-02

D · Potential for more than minimal harm 2024-08-06

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-08-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-08-06

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 2024-10-09

D · Potential for more than minimal harm 2024-08-06

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-08-06

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-08-06

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 2024-12-02

D · Potential for more than minimal harm 2024-08-06

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-01-30

F776 · Administration Deficiencies

Health

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Corrected 2024-02-15

E · Potential for more than minimal harm 2023-02-28

F635 · Resident Assessment and Care Planning Deficiencies

Health

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-02-28

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-02-28

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-02-28

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 2023-04-11

E · Potential for more than minimal harm 2023-02-28

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-02-28

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-02-28

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 2023-04-11

E · Potential for more than minimal harm 2023-02-28

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-02-28

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-02-28

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 2023-04-11

D · Potential for more than minimal harm 2023-02-28

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 2023-04-11

D · Potential for more than minimal harm 2023-02-28

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-02-28

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-02-28

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 2023-04-11

D · Potential for more than minimal harm 2023-02-28

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 2023-04-11

D · Potential for more than minimal harm 2023-02-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-04-11

C · Minimal harm 2023-02-28

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-04-11

E · Potential for more than minimal harm 2022-04-07

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-05-10

E · Potential for more than minimal harm 2022-04-07

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 2022-05-10

E · Potential for more than minimal harm 2022-04-07

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-05-10

E · Potential for more than minimal harm 2022-04-07

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-05-10

D · Potential for more than minimal harm 2022-04-07

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 2022-05-10

D · Potential for more than minimal harm 2022-04-07

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2022-05-10

D · Potential for more than minimal harm 2022-04-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-05-10

D · Potential for more than minimal harm 2022-04-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-05-10

D · Potential for more than minimal harm 2022-04-07

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2022-05-10

D · Potential for more than minimal harm 2022-04-07

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 2022-05-10

D · Potential for more than minimal harm 2022-04-07

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-05-10

D · Potential for more than minimal harm 2022-04-07

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 2022-05-10

D · Potential for more than minimal harm 2022-04-07

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 2022-05-10

F · Potential for more than minimal harm 2019-08-29

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2019-09-17

F · Potential for more than minimal harm 2019-08-29

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 2019-09-17

E · Potential for more than minimal harm 2019-08-29

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 2019-09-17

D · Potential for more than minimal harm 2019-08-29

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 2019-09-17

D · Potential for more than minimal harm 2019-08-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-09-17

D · Potential for more than minimal harm 2019-08-29

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 2019-09-17

D · Potential for more than minimal harm 2019-08-29

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2019-09-17

D · Potential for more than minimal harm 2019-08-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-09-17

Penalties and ownership

What sits behind the stars

$203,292 2024-08-06

Fine

Fine · fine $203,292

Fine

Ownership

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