Cycle 1
Health 2024-06-28 · Fire 2024-06-28
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rolla, MO
Aurora Health And Rehabilitation
1-star overall rating with 2-star inspections with $64,893 in total fines with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1200 Mccutchen Road, Rolla, MO
(573) 364-2311
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
116
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vertical Health Services
Operator or chain grouping
Approved since
2013-04-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 1 staffing / 4 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
0.64
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
2.39
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,772
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.36
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 21.88% · Performance 21.80% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.50
Baseline 11.45% · Performance 8.22% · Measure score 4.50 · Achievement 0 · Improvement 4.50
Total nurse turnover
1.64
Baseline 76.81% · Performance 65.67% · Measure score 1.64 · Achievement 0 · Improvement 1.64
Adjusted total nurse staffing
0
Baseline 3.50 hours · Performance 2.45 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.7% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 15.11% · Lower 95% interval 8.51% |
| Discharge to community | 54.88% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 44.34% · Lower 95% interval 41.8% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 85 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 26.32% |
53.69%
27.4 pts worse
|
Numerator 15 · Denominator 57 |
| Discharge mobility score | 17.54% |
50.94%
33.4 pts worse
|
Numerator 10 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 85 · Adjusted rate 2.17% |
| Healthcare-associated infections requiring hospitalization | 8.22% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 10.13% · Lower 95% interval 4.36% |
| Staff COVID-19 vaccination coverage | 0.93% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 107 |
| Staff flu vaccination coverage | 4.92% |
42%
37.1 pts worse
|
Numerator 9 · Denominator 183 |
| Discharge function score | 26.32% |
56.45%
30.1 pts worse
|
Numerator 15 · Denominator 57 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.8% |
84.8%
13 pts worse
|
93.4%
21.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.1% · Q2 73.4% · Q3 82.5% · Q4 88.1% · 4Q avg 71.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.1% |
90.9%
7.8 pts worse
|
95.5%
12.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
4.1%
3.3 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 63.4% |
14.7%
48.7 pts worse
|
11.4%
52 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.0% · Q2 61.4% · Q3 60.0% · Q4 63.5% · 4Q avg 63.4% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.5%
3.4 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.8% · Q4 3.1% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.2% |
25.3%
7.9 pts worse
|
19.6%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 27.9% · Q3 38.3% · Q4 38.5% · 4Q avg 33.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
25.0%
1.5 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 20.9% · Q3 26.7% · Q4 35.8% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 3.5% |
20.3%
16.8 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · Q3 4.9% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.0% |
19.8%
16.8 pts better
|
14.9%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.5% · Q3 5.3% · Q4 1.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 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% |
2.6%
2.6 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 | 18.2% |
18.1%
0.1 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 15.3% · Q3 23.0% · Q4 10.6% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.0%
1.7 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.6% · Q3 1.5% · Q4 4.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.4% |
66.4%
25 pts worse
|
81.7%
40.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 27.4% · Q3 59.8% · Q4 63.4% · 4Q avg 41.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.6% |
13.4%
10.2 pts worse
|
12.0%
11.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 28.8% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 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 | 27.4% |
63.5%
36.1 pts worse
|
79.7%
52.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 27.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
25.3%
3.2 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 31.8% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
20 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-11-24 · Fire 2021-11-24
27 health deficiencies
Top issue: Resident Rights (9 deficiencies)
15 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-07
F · Potential for more than minimal harm
2024-06-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-07
F · Potential for more than minimal harm
2024-06-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-06-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-06-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-07
F · Potential for more than minimal harm
2023-08-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
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 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-13
F · Potential for more than minimal harm
2023-08-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-11-13
F · Potential for more than minimal harm
2023-08-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-13
F · Potential for more than minimal harm
2023-08-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-13
F · Potential for more than minimal harm
2023-08-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
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
F · Potential for more than minimal harm
2023-08-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-08-31
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-10-09
E · Potential for more than minimal harm
2023-08-31
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-08-31
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 2023-10-09
F · Potential for more than minimal harm
2021-11-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-01-24
F · Potential for more than minimal harm
2021-11-24
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-15
F · Potential for more than minimal harm
2021-11-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-01-10
E · Potential for more than minimal harm
2021-11-24
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 2022-01-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-19
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 2025-12-04
D · Potential for more than minimal harm
2025-11-19
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 2025-12-04
D · Potential for more than minimal harm
2025-11-19
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 2025-12-04
D · Potential for more than minimal harm
2025-11-19
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-07-02
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-03-20
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 2025-04-11
D · Potential for more than minimal harm
2025-03-20
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 2025-04-11
D · Potential for more than minimal harm
2025-03-20
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 2025-04-11
E · Potential for more than minimal harm
2024-10-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-17
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 2024-11-07
J · Immediate jeopardy
2024-08-16
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 2024-08-08
F · Potential for more than minimal harm
2024-06-28
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 2024-08-07
E · Potential for more than minimal harm
2024-06-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-06-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-06-28
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 2024-08-07
E · Potential for more than minimal harm
2024-06-28
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 2024-08-07
E · Potential for more than minimal harm
2024-06-28
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 2024-08-07
D · Potential for more than minimal harm
2024-06-28
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 2024-08-07
D · Potential for more than minimal harm
2024-06-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-02-22
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 2024-03-16
E · Potential for more than minimal harm
2024-02-22
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 2024-03-16
D · Potential for more than minimal harm
2024-01-25
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 2024-03-21
D · Potential for more than minimal harm
2024-01-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-21
E · Potential for more than minimal harm
2023-10-20
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 2023-11-13
F · Potential for more than minimal harm
2023-08-31
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 2023-09-29
E · Potential for more than minimal harm
2023-08-31
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 2023-09-29
E · Potential for more than minimal harm
2023-08-31
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 2023-11-13
E · Potential for more than minimal harm
2023-08-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-31
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 2023-11-13
E · Potential for more than minimal harm
2023-08-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-31
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 2023-09-29
E · Potential for more than minimal harm
2023-08-31
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 2023-11-13
E · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-13
C · Minimal harm
2023-08-31
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2023-09-29
C · Minimal harm
2023-08-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-29
C · Minimal harm
2023-08-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-09-29
C · Minimal harm
2023-08-31
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-09-29
C · Minimal harm
2023-08-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-29
C · Minimal harm
2023-08-31
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 2023-09-29
B · Minimal harm
2023-08-31
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 2023-09-29
E · Potential for more than minimal harm
2023-07-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-06
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 2023-08-11
K · Immediate jeopardy
2021-11-24
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 2022-01-10
F · Potential for more than minimal harm
2021-11-24
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 2022-01-10
F · Potential for more than minimal harm
2021-11-24
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-24
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 2022-01-10
F · Potential for more than minimal harm
2021-11-24
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-01-10
E · Potential for more than minimal harm
2021-11-24
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 2022-01-10
E · Potential for more than minimal harm
2021-11-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-01-10
E · Potential for more than minimal harm
2021-11-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-01-10
E · Potential for more than minimal harm
2021-11-24
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 2022-01-24
E · Potential for more than minimal harm
2021-11-24
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 2022-01-24
E · Potential for more than minimal harm
2021-11-24
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 2022-01-10
E · Potential for more than minimal harm
2021-11-24
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 2022-01-10
E · Potential for more than minimal harm
2021-11-24
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 2022-01-10
E · Potential for more than minimal harm
2021-11-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-01-10
E · Potential for more than minimal harm
2021-11-24
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 2022-01-10
D · Potential for more than minimal harm
2021-11-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-10
Penalties and ownership
What sits behind the stars
$14,433
2024-06-28
Fine
Fine · fine $14,433
Fine
$4,587
2023-09-25
Fine
Fine · fine $4,587
Fine
$13,762
2023-09-05
Fine
Fine · fine $13,762
Fine
$13,762
2023-07-31
Fine
Fine · fine $13,762
Fine
$4,587
2023-06-26
Fine
Fine · fine $4,587
Fine
$13,762
2023-06-05
Fine
Fine · fine $13,762
Fine
Ownership
Kuhn, Elizabeth
Operational/Managerial Control · Individual
Maylack, Elizabeth
Operational/Managerial Control · Individual
Mccutchen Rd Consulting LLC
Operational/Managerial Control · Organization
Miller, William
Operational/Managerial Control · Individual
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#3
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