Cycle 1
Health 2025-04-24 · Fire 2025-04-24
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Florence, KY
Belmont Terrace Nursing and Rehabilitation Center
1-star overall rating with 1-star inspections with abuse icon flag with $35,980 in total fines with 4 recent health deficiencies
7300 Woodspoint Drive, Florence, KY
(859) 371-5731
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
151
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Encore Health Partners
Operator or chain grouping
Approved since
1969-12-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 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
0.40
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,203
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.44
Baseline 22.62% · Performance 19.30% · Measure score 5.44 · Achievement 4.59 · Improvement 5.44
Healthcare-associated infections
3.03
Baseline 8.65% · Performance 7.36% · Measure score 3.03 · Achievement 1.59 · Improvement 3.03
Total nurse turnover
0
Baseline 80.82% · Performance 80.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.33 hours · Performance 2.59 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 11.48% · Lower 95% interval 6.7% |
| Discharge to community | 30.23% |
50.57%
20.3 pts worse
|
Worse than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 18.01% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 11.11% |
53.69%
42.6 pts worse
|
Numerator 3 · Denominator 27 |
| Discharge mobility score | 7.41% |
50.94%
43.5 pts worse
|
Numerator 2 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 9.3% |
2.29%
7 pts worse
|
Numerator 4 · Denominator 43 · Adjusted rate 7.55% |
| Healthcare-associated infections requiring hospitalization | 7.36% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 13.16% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 22.22% |
56.45%
34.2 pts worse
|
Numerator 6 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.81% |
25.2%
10.4 pts worse
|
Numerator 4 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
1.9
1.7 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
94.3%
3.2 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 98.2% · Q3 96.3% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.3% |
96.2%
4.9 pts worse
|
95.5%
4.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.8%
1.1 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.6% · Q3 3.7% · Q4 1.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.3% |
15.2%
4.1 pts worse
|
11.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 12.5% · Q3 25.3% · Q4 20.2% · 4Q avg 19.3% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.7%
1.7 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.7% · Q3 2.9% · Q4 5.1% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.1% |
29.6%
0.5 pts worse
|
19.6%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 30.4% · Q3 31.1% · Q4 30.1% · 4Q avg 30.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
17.6%
4 pts worse
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 22.7% · Q3 19.0% · Q4 25.0% · 4Q avg 21.6% · 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 | 12.2% |
17.3%
5.1 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 9.5% · Q3 3.0% · Q4 5.5% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
15.6%
1.3 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 21.9% · Q3 15.0% · Q4 3.2% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.7%
1.2 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.4% · Q3 0.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
19.8%
0.8 pts worse
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 25.5% · Q3 25.2% · Q4 13.2% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.5%
0.1 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.5% · Q3 5.3% · Q4 5.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.4% |
83.8%
9.4 pts worse
|
81.7%
7.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 71.4% · Q3 88.6% · Q4 91.5% · 4Q avg 74.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
13.9%
4.3 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 11.1% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.8%
1.8 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 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 | 70.6% |
83.6%
13 pts worse
|
79.7%
9.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
24.5%
5.2 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 33.3% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
32 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2021-05-14 · Fire 2021-05-14
18 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-08
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-08
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 2024-04-12
F · Potential for more than minimal harm
2024-03-08
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-08
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 2024-04-12
E · Potential for more than minimal harm
2024-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-08
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-04-12
D · Potential for more than minimal harm
2021-05-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-05-14
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 2021-06-10
D · Potential for more than minimal harm
2021-05-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-05-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-06-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
E · Potential for more than minimal harm
2025-04-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
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 2025-05-31
D · Potential for more than minimal harm
2025-04-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-21
H · Actual harm
2024-03-08
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 2024-04-30
G · Actual harm
2024-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-03-08
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 2024-06-05
F · Potential for more than minimal harm
2024-03-08
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 2024-04-30
F · Potential for more than minimal harm
2024-03-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-03-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-03-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-08
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 2024-04-30
E · Potential for more than minimal harm
2024-03-08
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 2024-04-30
E · Potential for more than minimal harm
2024-03-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-08
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 2024-05-01
E · Potential for more than minimal harm
2024-03-08
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 2024-06-05
E · Potential for more than minimal harm
2024-03-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-08
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
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 2024-06-05
D · Potential for more than minimal harm
2024-03-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
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 2024-06-05
D · Potential for more than minimal harm
2024-03-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
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 2024-04-30
D · Potential for more than minimal harm
2024-03-08
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 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-30
J · Immediate jeopardy
2021-05-14
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 2021-06-24
J · Immediate jeopardy
2021-05-14
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 2021-06-24
J · Immediate jeopardy
2021-05-14
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 2021-06-24
J · Immediate jeopardy
2021-05-14
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 2021-06-24
J · Immediate jeopardy
2021-05-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-06-24
J · Immediate jeopardy
2021-05-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-24
F · Potential for more than minimal harm
2021-05-14
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 2021-06-24
F · Potential for more than minimal harm
2021-05-14
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 2021-06-24
F · Potential for more than minimal harm
2021-05-14
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 2021-06-24
F · Potential for more than minimal harm
2021-05-14
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2021-06-24
E · Potential for more than minimal harm
2021-05-14
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 2021-06-24
E · Potential for more than minimal harm
2021-05-14
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 2021-06-24
E · Potential for more than minimal harm
2021-05-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-24
E · Potential for more than minimal harm
2021-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-24
D · Potential for more than minimal harm
2021-05-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-06-24
D · Potential for more than minimal harm
2021-05-14
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 2021-06-24
D · Potential for more than minimal harm
2021-05-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-06-24
D · Potential for more than minimal harm
2021-05-14
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 2021-06-24
Penalties and ownership
What sits behind the stars
$5,346
2024-03-08
Fine
Fine · fine $5,346
Fine
$6,682
2024-03-08
Fine
Fine · fine $6,682
Fine
$16,801
2024-03-08
Fine
Fine · fine $16,801
Fine
$0
2024-03-08
Payment Denial
Payment Denial · denial start 2024-04-07 · 59 days
59 day denial
$2,258
2024-01-08
Fine
Fine · fine $2,258
Fine
$1,748
2024-01-02
Fine
Fine · fine $1,748
Fine
$3,145
2023-12-11
Fine
Fine · fine $3,145
Fine
Ownership
Encore Parent Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
7300 Woodspoint Drive Realty LLC
5% Or Greater Mortgage Interest · Organization
Bloom, David
5% Or Greater Indirect Ownership Interest · Individual
Dwight Mortgage Trust LLC
5% Or Greater Mortgage Interest · Organization
Encore Health Partners 2 LLC
Operational/Managerial Control · Organization
Encore Investors 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Encore Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Fischl, Mayer
Operational/Managerial Control · Individual
Fischl, Mayer
Corporate Officer · Individual
Graves, Kenneth
Operational/Managerial Control · Individual
Grinspan, Eli
5% Or Greater Indirect Ownership Interest · Individual
Grinspan, Eli
Operational/Managerial Control · Individual
Grinspan, Eli
Corporate Officer · Individual
Grinspan, Isaac
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Shemwell, Joan
Operational/Managerial Control · Individual
Thompson, Monica
Operational/Managerial Control · Individual
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