Cycle 1
Health 2025-05-08 · Fire 2025-05-08
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Brewster, MA
Cape Cod Post Acute Care
1-star overall rating with 1-star inspections with $298,483 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
383 South Orleans Road, Brewster, MA
(508) 240-3500
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
135
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1995-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 health / 2 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
0.83
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,721
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.11
Baseline 21.54% · Performance 19.06% · Measure score 5.11 · Achievement 5.11 · Improvement 4.99
Healthcare-associated infections
1.71
Baseline 7.45% · Performance 7.32% · Measure score 1.71 · Achievement 1.71 · Improvement 0.01
Total nurse turnover
2.60
Baseline 47.22% · Performance 53.06% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Adjusted total nurse staffing
0.92
Baseline 3.13 hours · Performance 3.34 hours · Measure score 0.92 · Achievement 0.92 · Improvement 0.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 424 · Observed rate 7.78% · Lower 95% interval 7.14% |
| Discharge to community | 60.7% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 423 · Observed rate 55.56% · Lower 95% interval 56.11% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.65% |
95.27%
4.4 pts better
|
Numerator 288 · Denominator 289 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 289 |
| Discharge self-care score | 59.65% |
53.69%
6 pts better
|
Numerator 102 · Denominator 171 |
| Discharge mobility score | 39.18% |
50.94%
11.8 pts worse
|
Numerator 67 · Denominator 171 |
| Pressure ulcers or injuries, new or worsened | 2.42% |
2.29%
0.1 pts worse
|
Numerator 7 · Denominator 289 · Adjusted rate 3.01% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 221 · Observed rate 6.33% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 7.3% |
8.2%
0.9 pts worse
|
Numerator 10 · Denominator 137 |
| Staff flu vaccination coverage | 30.28% |
42%
11.7 pts worse
|
Numerator 43 · Denominator 142 |
| Discharge function score | 60.23% |
56.45%
3.8 pts better
|
Numerator 103 · Denominator 171 |
| Transfer of health information to provider | 99.24% |
95.95%
3.3 pts better
|
Numerator 130 · Denominator 131 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 114 · Denominator 114 |
| Resident COVID-19 vaccinations up to date | 19.02% |
25.2%
6.2 pts worse
|
Numerator 31 · Denominator 163 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.9
0.2 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
92.2%
1.2 pts better
|
93.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 92.9% · Q3 89.2% · Q4 94.7% · 4Q avg 93.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.4% |
94.8%
1.4 pts worse
|
95.5%
2.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.5%
1.5 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.1% · Q3 4.3% · Q4 4.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 33.5% |
12.0%
21.5 pts worse
|
11.4%
22.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 32.6% · Q3 40.7% · Q4 42.0% · 4Q avg 33.5% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.2%
3.5 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 9.7% · Q3 8.2% · Q4 4.1% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
19.2%
5.1 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 11.5% · Q3 13.2% · Q4 17.3% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.9% |
22.5%
2.4 pts worse
|
16.7%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 23.6% · Q3 23.3% · Q4 26.2% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.8% |
17.7%
5.1 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 22.9% · Q3 22.6% · Q4 16.0% · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.9% |
17.6%
15.3 pts worse
|
14.9%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 32.9% · Q3 37.8% · Q4 24.7% · 4Q avg 32.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.0%
0.9 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 0.0% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.0% |
21.7%
11.3 pts worse
|
19.8%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 31.3% · Q3 24.5% · Q4 30.6% · 4Q avg 33.0% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.6%
0.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.2% · Q3 2.8% · Q4 4.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
77.1%
7.7 pts worse
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.7% · Q2 56.0% · Q3 71.6% · Q4 84.5% · 4Q avg 69.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
11.8%
2.8 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.4% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.9% |
77.7%
34.8 pts worse
|
79.7%
36.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
25.8%
2.6 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 20.6% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-19 · Fire 2024-03-19
32 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2022-08-24 · Fire 2022-08-24
28 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-08
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-08
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 2025-06-03
D · Potential for more than minimal harm
2025-05-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-03
C · Minimal harm
2025-05-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-03-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-04-25
F · Potential for more than minimal harm
2024-03-19
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 2024-04-25
F · Potential for more than minimal harm
2024-03-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-25
F · Potential for more than minimal harm
2024-03-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
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 2024-04-25
D · Potential for more than minimal harm
2024-03-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-19
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-25
F · Potential for more than minimal harm
2022-08-24
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-08-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-08-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-08-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-08-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-08-24
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 2022-10-13
D · Potential for more than minimal harm
2022-08-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-08-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-08-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-13
C · Minimal harm
2022-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-08
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 2025-06-03
E · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-08
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 2025-06-03
D · Potential for more than minimal harm
2025-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-08
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-08
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 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-20
D · Potential for more than minimal harm
2024-07-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-05-21
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 2024-06-09
H · Actual harm
2024-03-19
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 2024-04-26
H · Actual harm
2024-03-19
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 2024-04-26
H · Actual harm
2024-03-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-26
G · Actual harm
2024-03-19
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 2024-04-26
G · Actual harm
2024-03-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-19
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-04-24
F · Potential for more than minimal harm
2024-03-19
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 2024-04-24
E · Potential for more than minimal harm
2024-03-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-26
E · Potential for more than minimal harm
2024-03-19
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 2024-04-26
E · Potential for more than minimal harm
2024-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
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 2024-04-26
D · Potential for more than minimal harm
2024-03-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
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 2024-04-24
D · Potential for more than minimal harm
2024-03-19
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 2024-04-26
D · Potential for more than minimal harm
2024-03-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-03-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
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 2024-04-26
D · Potential for more than minimal harm
2024-03-19
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 2024-05-24
D · Potential for more than minimal harm
2024-03-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-19
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 2024-04-24
B · Minimal harm
2024-03-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-24
B · Minimal harm
2024-03-19
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-04-24
E · Potential for more than minimal harm
2023-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-20
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 2023-10-16
D · Potential for more than minimal harm
2023-09-20
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 2023-10-16
D · Potential for more than minimal harm
2023-09-20
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 2023-10-16
H · Actual harm
2022-08-24
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 2022-09-30
H · Actual harm
2022-08-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-07
G · Actual harm
2022-08-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-24
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 2022-10-14
F · Potential for more than minimal harm
2022-08-24
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 2022-10-14
F · Potential for more than minimal harm
2022-08-24
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 2022-10-14
F · Potential for more than minimal harm
2022-08-24
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 2022-10-14
F · Potential for more than minimal harm
2022-08-24
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 2022-10-05
E · Potential for more than minimal harm
2022-08-24
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 2022-10-14
E · Potential for more than minimal harm
2022-08-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-24
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 2022-10-14
E · Potential for more than minimal harm
2022-08-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-06
E · Potential for more than minimal harm
2022-08-24
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-08-24
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 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-24
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 2022-10-14
D · Potential for more than minimal harm
2022-08-24
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 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-14
Penalties and ownership
What sits behind the stars
$298,483
2024-03-19
Fine
Fine · fine $298,483
Fine
$0
2024-03-19
Payment Denial
Payment Denial · denial start 2024-05-02 · 38 days
38 day denial
Ownership
Quinto Nexgen LLC
5% Or Greater Direct Ownership Interest · Organization
Ukr Nexgen LLC
5% Or Greater Direct Ownership Interest · Organization
Forbright Bank
5% Or Greater Mortgage Interest · Organization
Lordan, Nancy
Operational/Managerial Control · Individual
Marquis Limited LLC
Operational/Managerial Control · Organization
Nfr 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Posen, Mindee
Operational/Managerial Control · Individual
Reliant Pro Rehab LLC
Operational/Managerial Control · Organization
Rsbrmk Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sk Nexgen Tr
5% Or Greater Indirect Ownership Interest · Organization
Tryko Nexgen Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Uak 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Yk Nexgen Tr
5% Or Greater Indirect Ownership Interest · Organization
Yr Nexgen Tr
5% Or Greater Indirect Ownership Interest · Organization
Zanfes, Zachary
Operational/Managerial Control · Individual
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#3
Windsor Nursing & Retirement Home
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1-star overall rating with 2-star inspections with $12,386 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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