Cycle 1
Health 2024-08-28 · Fire 2024-08-28
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Madison, OH
Cardinal Woods Skilled Nursing & Rehab Ctr
1-star overall rating with 1-star inspections with abuse icon flag with $27,318 in total fines with 7 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
6831 Chapel Road, Madison, OH
(440) 428-5103
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aom Healthcare
Operator or chain grouping
Approved since
1985-06-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 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
0.36
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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
0
Baseline 43.90% · Performance 71.74% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 15.79% · Lower 95% interval 7.33% |
| Discharge to community | 55.72% |
50.57%
5.1 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 51.72% · Lower 95% interval 37.7% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 42.86% |
42%
0.9 pts better
|
Numerator 60 · Denominator 140 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.3%
1.1 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.4% · Q3 4.5% · Q4 6.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.0% |
26.1%
7.1 pts better
|
11.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 16.9% · Q4 25.3% · 4Q avg 19.0% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
6.2%
0.7 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.5% · Q3 13.1% · Q4 4.9% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.8% |
25.4%
9.4 pts worse
|
19.6%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 35.4% · Q3 35.7% · Q4 35.4% · 4Q avg 34.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
11.5%
4.4 pts worse
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 17.0% · Q3 14.5% · Q4 11.7% · 4Q avg 15.9% · 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 | 4.5% |
7.7%
3.2 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.1% · Q3 3.6% · Q4 6.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
6.2%
2.2 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.2% · Q3 2.5% · Q4 6.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.5%
0.1 pts worse
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
21.7%
5.6 pts better
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 25.6% · Q3 14.1% · Q4 10.9% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
3.7%
2.9 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
78.1%
16.9 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 95.0% · Q3 97.0% · Q4 93.9% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
12.5%
3.5 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 18.2% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.2%
3.1 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
75.6%
19.5 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.3% |
25.1%
11.8 pts better
|
23.9%
10.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 13.6% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-27 · Fire 2022-06-27
21 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-05-16 · Fire 2019-05-16
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
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 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
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 2024-09-30
E · Potential for more than minimal harm
2024-08-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-30
F · Potential for more than minimal harm
2022-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-07-22
F · Potential for more than minimal harm
2019-05-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-06-15
F · Potential for more than minimal harm
2019-05-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-06-15
F · Potential for more than minimal harm
2019-05-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-06-15
F · Potential for more than minimal harm
2019-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-15
F · Potential for more than minimal harm
2019-05-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2019-06-15
E · Potential for more than minimal harm
2019-05-16
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 2019-06-15
E · Potential for more than minimal harm
2019-05-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-15
E · Potential for more than minimal harm
2019-05-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-06-15
B · Minimal harm
2019-05-16
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-05-24
B · Minimal harm
2019-05-16
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-05-24
Inspection history
Recent health citations
G · Actual harm
2025-12-03
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 2025-12-04
G · Actual harm
2025-04-10
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 2025-04-11
G · Actual harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-04-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-04-10
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 2025-04-11
D · Potential for more than minimal harm
2025-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-08-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-30
G · Actual harm
2024-06-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-04-11
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 2024-04-23
E · Potential for more than minimal harm
2024-02-07
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 2024-02-19
G · Actual harm
2023-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-14
F · Potential for more than minimal harm
2022-06-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
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 2022-07-22
F · Potential for more than minimal harm
2022-06-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
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 2022-07-22
F · Potential for more than minimal harm
2022-06-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
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 2022-07-22
E · Potential for more than minimal harm
2022-06-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-06-27
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 2022-07-22
D · Potential for more than minimal harm
2022-06-27
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 2022-07-22
D · Potential for more than minimal harm
2022-06-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-27
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 2022-07-22
D · Potential for more than minimal harm
2022-06-27
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 2022-07-22
D · Potential for more than minimal harm
2022-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-22
F · Potential for more than minimal harm
2019-05-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-15
F · Potential for more than minimal harm
2019-05-16
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2019-06-15
E · Potential for more than minimal harm
2019-05-16
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 2019-06-15
E · Potential for more than minimal harm
2019-05-16
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 2019-06-15
D · Potential for more than minimal harm
2019-05-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-16
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 2019-06-15
D · Potential for more than minimal harm
2019-05-16
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 2019-06-15
D · Potential for more than minimal harm
2019-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-15
Penalties and ownership
What sits behind the stars
$16,801
2024-06-28
Fine
Fine · fine $16,801
Fine
$10,517
2023-12-05
Fine
Fine · fine $10,517
Fine
Ownership
Pointe Woods Investment LLC
5% Or Greater Direct Ownership Interest · Organization
Goldstein, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Sherman, Alexander
5% Or Greater Indirect Ownership Interest · Individual
Sherman, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Sherman, Alexander
Operational/Managerial Control · Individual
Sherman, Samuel
Operational/Managerial Control · Individual
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