Cycle 1
Health 2025-04-28 · Fire 2025-04-28
38 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Kansas City, MO
Bridgewood Health Care Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $611,126 in total fines with 38 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
11515 Troost, Kansas City, MO
(816) 943-0101
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
166
Certified beds
Average residents
152
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Reliant Care Management
Operator or chain grouping
Approved since
2008-08-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 1 overall / 2 health / 1 staffing / 2 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
0.09
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.58
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.07
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.49
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
1.89
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.08
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.08
CMS adjusted RN staffing hours
Adjusted total hours
1.87
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,027
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.85
Baseline 73.58% · Performance 62.12% · Measure score 1.85 · Achievement 0 · Improvement 1.85
Adjusted total nurse staffing
1
Baseline 1.89 hours · Performance 2.47 hours · Measure score 1 · Achievement 0 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.59% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 126 |
| Staff flu vaccination coverage | 31.62% |
42%
10.4 pts worse
|
Numerator 37 · Denominator 117 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 7.4 |
2.3
5.1 pts worse
|
1.8
5.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 7.4 · Observed 6.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 16.6% |
84.8%
68.2 pts worse
|
93.4%
76.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 23.6% · Q3 11.8% · Q4 19.5% · 4Q avg 16.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 34.9% |
90.9%
56 pts worse
|
95.5%
60.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 34.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
4.1%
3 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 0.7% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.7% |
14.7%
20 pts worse
|
11.4%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 10.7% · Q3 49.6% · Q4 78.9% · 4Q avg 34.7% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.5%
2.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.2% · Q3 13.4% · Q4 6.6% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.3% |
25.3%
14 pts worse
|
19.6%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 44.4% · Q3 38.7% · Q4 28.5% · 4Q avg 39.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 42.3% |
25.0%
17.3 pts worse
|
16.7%
25.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 44.0% · Q3 34.6% · Q4 44.4% · 4Q avg 42.3% · 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 | 49.7% |
20.3%
29.4 pts worse
|
16.3%
33.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.4% · Q2 48.8% · Q3 29.0% · Q4 36.6% · 4Q avg 49.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 41.5% |
19.8%
21.7 pts worse
|
14.9%
26.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.5% · Q2 41.1% · Q3 23.9% · Q4 24.5% · 4Q avg 41.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.4%
0.7 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.7% · 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 | 9.7% |
18.1%
8.4 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 12.8% · Q3 8.0% · Q4 11.0% · 4Q avg 9.7% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.0%
2.4 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.7% · Q3 2.8% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 1.7% |
66.4%
64.7 pts worse
|
81.7%
80 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 34.2% |
13.4%
20.8 pts worse
|
12.0%
22.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 40.0% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
25.3%
6.3 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 13.3% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-07 · Fire 2023-05-07
46 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
18 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Cycle 3
Health 2021-05-27 · Fire 2021-05-27
28 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (11 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2025-04-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-12
F · Potential for more than minimal harm
2023-05-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Not marked corrected
E · Potential for more than minimal harm
2023-05-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
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 2023-06-21
E · Potential for more than minimal harm
2023-05-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-21
F · Potential for more than minimal harm
2021-05-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-07-07
E · Potential for more than minimal harm
2021-05-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-07-07
E · Potential for more than minimal harm
2021-05-27
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-07-07
Inspection history
Recent health citations
G · Actual harm
2026-01-08
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Not marked corrected
G · Actual harm
2025-12-22
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.
Not marked corrected
J · Immediate jeopardy
2025-11-25
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 2025-11-26
E · Potential for more than minimal harm
2025-11-25
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-20
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-29
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-10-13
G · Actual harm
2025-08-22
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.
Not marked corrected
E · Potential for more than minimal harm
2025-08-22
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-08-22
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 2025-10-06
D · Potential for more than minimal harm
2025-08-22
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 2025-10-06
D · Potential for more than minimal harm
2025-08-22
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-07-31
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 2025-09-12
E · Potential for more than minimal harm
2025-07-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-07-31
F918 · Environmental Deficiencies
Health
Provide a bathroom in or located near each resident’s room.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-28
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
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 2025-06-12
E · Potential for more than minimal harm
2025-04-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
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 2025-06-12
E · Potential for more than minimal harm
2025-04-28
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
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 2025-06-12
E · Potential for more than minimal harm
2025-04-28
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 2025-06-12
E · Potential for more than minimal harm
2025-04-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-28
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 2025-06-12
E · Potential for more than minimal harm
2025-04-28
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 2025-06-12
D · Potential for more than minimal harm
2025-04-28
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 2025-06-12
D · Potential for more than minimal harm
2025-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-28
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 2025-06-12
D · Potential for more than minimal harm
2025-04-28
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-28
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 2025-06-12
J · Immediate jeopardy
2025-03-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-03-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-03-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-25
K · Immediate jeopardy
2025-01-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-31
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-03
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 2025-02-14
D · Potential for more than minimal harm
2025-01-03
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-12-19
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 2025-02-14
E · Potential for more than minimal harm
2024-12-19
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 2025-03-10
E · Potential for more than minimal harm
2024-12-19
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 2025-02-02
E · Potential for more than minimal harm
2024-12-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-02-02
E · Potential for more than minimal harm
2024-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-02
J · Immediate jeopardy
2024-11-15
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 2024-11-05
E · Potential for more than minimal harm
2024-10-04
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-04
J · Immediate jeopardy
2024-09-12
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 2024-10-27
D · Potential for more than minimal harm
2024-09-12
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 2024-10-27
D · Potential for more than minimal harm
2024-09-12
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 2024-10-27
E · Potential for more than minimal harm
2024-08-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-15
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-15
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 2024-09-27
D · Potential for more than minimal harm
2024-08-15
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 2024-08-04
G · Actual harm
2024-07-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-22
K · Immediate jeopardy
2024-06-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-25
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-05-30
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-25
J · Immediate jeopardy
2024-05-03
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 2024-04-26
E · Potential for more than minimal harm
2024-05-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-25
G · Actual harm
2024-02-09
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 2024-02-05
E · Potential for more than minimal harm
2024-02-09
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-09
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 2024-01-20
J · Immediate jeopardy
2023-12-21
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 2024-02-05
D · Potential for more than minimal harm
2023-12-21
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 2024-01-25
D · Potential for more than minimal harm
2023-12-21
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-01-25
D · Potential for more than minimal harm
2023-12-21
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-21
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 2024-01-20
J · Immediate jeopardy
2023-11-30
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 2024-02-05
D · Potential for more than minimal harm
2023-11-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-30
J · Immediate jeopardy
2023-11-16
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 2024-02-05
F · Potential for more than minimal harm
2023-11-16
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 2023-12-25
D · Potential for more than minimal harm
2023-11-16
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 2023-12-25
D · Potential for more than minimal harm
2023-11-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-25
G · Actual harm
2023-10-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-10-18
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-10-06
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-08-30
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 2023-09-30
D · Potential for more than minimal harm
2023-08-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-05-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
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 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
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 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
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 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-07
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 2023-06-21
E · Potential for more than minimal harm
2023-05-07
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-07
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-07
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-07
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 2023-06-21
C · Minimal harm
2023-05-07
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-06-21
G · Actual harm
2023-03-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-02-27
E · Potential for more than minimal harm
2021-05-27
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 2021-07-07
E · Potential for more than minimal harm
2021-05-27
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 2021-07-07
E · Potential for more than minimal harm
2021-05-27
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 2021-07-07
E · Potential for more than minimal harm
2021-05-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-05-27
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-05-27
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 2021-07-07
D · Potential for more than minimal harm
2021-05-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-05-27
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 2021-07-07
Penalties and ownership
What sits behind the stars
$22,315
2026-01-08
Fine
Fine · fine $22,315
Fine
$22,315
2025-12-22
Fine
Fine · fine $22,315
Fine
$37,480
2025-11-20
Fine
Fine · fine $37,480
Fine
$12,425
2025-07-31
Fine
Fine · fine $12,425
Fine
$14,768
2025-04-28
Fine
Fine · fine $14,768
Fine
$0
2025-04-28
Payment Denial
Payment Denial · denial start 2025-06-06 · 6 days
6 day denial
$161,129
2024-12-19
Fine
Fine · fine $161,129
Fine
$12,038
2024-11-15
Fine
Fine · fine $12,038
Fine
$51,266
2024-08-15
Fine
Fine · fine $51,266
Fine
$0
2024-08-15
Payment Denial
Payment Denial · denial start 2024-10-16 · 11 days
11 day denial
$14,050
2024-07-31
Fine
Fine · fine $14,050
Fine
$54,406
2024-05-30
Fine
Fine · fine $54,406
Fine
$16,801
2024-05-03
Fine
Fine · fine $16,801
Fine
$192,133
2023-11-16
Fine
Fine · fine $192,133
Fine
$0
2023-11-16
Payment Denial
Payment Denial · denial start 2023-12-27 · 93 days
93 day denial
Ownership
Arshad, Abdullah
Operational/Managerial Control · Individual
Destefane, Richard
Operational/Managerial Control · Individual
Moore, Rhonda
Operational/Managerial Control · Individual
Reliant Care Management Company LLC
Operational/Managerial Control · Organization
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#3
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