Philadelphia, PA

Care Pavilion Nursing And Rehabilitation Center

1-star overall rating with 1-star inspections with abuse icon flag with $390,201 in total fines with 38 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

6212 Walnut Street, Philadelphia, PA

(215) 476-6264

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

396

Certified beds

Average residents

338

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Bedrock Care

Operator or chain grouping

Approved since

1993-05-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

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

0.34

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.96

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.05

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.36

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.30

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

2.98

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.43

CMS adjusted RN staffing hours

Adjusted total hours

4.29

CMS adjusted total nurse staffing hours

Case-mix index

1.07

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

25%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,221

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

50.90

Composite VBP score used to determine payment impact.

Payment multiplier

1.0051

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

7.13

Baseline 43.10% · Performance 34.55% · Measure score 7.13 · Achievement 7.13 · Improvement 4.18

Adjusted total nurse staffing

3.05

Baseline 3.42 hours · Performance 3.95 hours · Measure score 3.05 · Achievement 3.05 · Improvement 1.72

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.29%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 83 · Observed rate 12.05% · Lower 95% interval 7.19%
Discharge to community	46.95%	50.57% 3.6 pts worse	No Different than the National Rate · Eligible stays 72 · Observed rate 30.56% · Lower 95% interval 34.28%
Medicare spending per beneficiary	0.94	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 46 · Denominator 46
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 46
Discharge self-care score	58.82%	53.69% 5.1 pts better	Numerator 20 · Denominator 34
Discharge mobility score	20.59%	50.94% 30.3 pts worse	Numerator 7 · Denominator 34
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 46 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	70.84%	8.2% 62.6 pts better	Numerator 260 · Denominator 367
Staff flu vaccination coverage	75.6%	42% 33.6 pts better	Numerator 282 · Denominator 373
Discharge function score	47.06%	56.45% 9.4 pts worse	Numerator 16 · Denominator 34
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	8%	25.2% 17.2 pts worse	Numerator 2 · Denominator 25

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.1	1.7 0.4 pts worse	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.6 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	1.2 0.7 pts worse	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	80.1%	86.9% 6.8 pts worse	93.4% 13.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 81.0% · Q3 80.9% · Q4 72.2% · 4Q avg 80.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.5%	93.5% 2 pts better	95.5% About the same	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5%
Percentage of long-stay residents experiencing one or more falls with major injury	1.9%	3.2% 1.3 pts better	3.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.2% · Q3 2.1% · Q4 1.6% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.2%	6.5% 5.3 pts better	11.4% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.8% · Q4 0.0% · 4Q avg 1.2%
Percentage of long-stay residents who lose too much weight	11.3%	6.5% 4.8 pts worse	5.4% 5.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.8% · Q3 14.9% · Q4 11.0% · 4Q avg 11.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.3%	19.9% 8.6 pts better	19.6% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.2% · Q3 10.7% · Q4 13.0% · 4Q avg 11.3%
Percentage of long-stay residents who received an antipsychotic medication	26.0%	18.7% 7.3 pts worse	16.7% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 29.4% · Q3 23.0% · Q4 22.1% · 4Q avg 26.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	25.7%	19.6% 6.1 pts worse	16.3% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 27.3% · Q3 25.6% · Q4 25.5% · 4Q avg 25.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.0%	18.3% 6.7 pts worse	14.9% 10.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 27.9% · Q3 29.0% · Q4 29.7% · 4Q avg 25.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	0.9% 0.7 pts worse	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 1.3% · Q4 1.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	1.7% 1.2 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 1.5% · Q3 0.0% · Q4 0.3% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.2%	26.4% 1.8 pts worse	19.8% 8.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 27.4% · Q3 27.2% · Q4 29.9% · 4Q avg 28.2%
Percentage of long-stay residents with pressure ulcers	7.3%	5.3% 2 pts worse	5.1% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.2% · Q3 11.2% · Q4 7.6% · 4Q avg 7.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	20.6%	68.9% 48.3 pts worse	81.7% 61.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 15.8% · Q3 24.9% · Q4 21.6% · 4Q avg 20.6%
Percentage of short-stay residents who had an outpatient emergency department visit	9.3%	9.8% 0.5 pts better	12.0% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 12.5% · Expected 15.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.5% 0.1 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.0% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	12.7%	68.7% 56 pts worse	79.7% 67 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 12.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.9%	23.1% 4.8 pts worse	23.9% 4 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 37.5% · Expected 32.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-18 · Fire 2025-02-18

38 health deficiencies

Top issue: Quality of Life and Care (13 deficiencies)

10 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-05-31 · Fire 2024-05-31

19 health deficiencies

Top issue: Environmental (5 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 3 Health 2024-01-19 · Fire 2024-01-19

43 health deficiencies

Top issue: Quality of Life and Care (17 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

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 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

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 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2025-04-19

E · Potential for more than minimal harm 2025-02-18

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-04-19

F · Potential for more than minimal harm 2024-05-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

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 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-16

E · Potential for more than minimal harm 2024-05-31

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-05-31

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-09-16

C · Minimal harm 2024-05-31

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-08-30

F · Potential for more than minimal harm 2024-01-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-02-08

F · Potential for more than minimal harm 2024-01-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-02-08

F · Potential for more than minimal harm 2024-01-19

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-02-08

F · Potential for more than minimal harm 2024-01-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-02-08

F · Potential for more than minimal harm 2024-01-19

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-02-08

F · Potential for more than minimal harm 2024-01-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-19

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-19

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 2024-02-08

E · Potential for more than minimal harm 2024-01-19

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-02-08

E · Potential for more than minimal harm 2024-01-19

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-02-08

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-22

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 2026-01-30

D · Potential for more than minimal harm 2025-12-22

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2026-01-30

D · Potential for more than minimal harm 2025-12-22

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 2026-01-30

D · Potential for more than minimal harm 2025-12-22

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 2026-01-30

D · Potential for more than minimal harm 2025-12-22

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 2026-01-30

E · Potential for more than minimal harm 2025-11-13

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 2025-12-09

G · Actual harm 2025-09-11

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 2025-09-05

D · Potential for more than minimal harm 2025-09-11

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 2025-10-11

E · Potential for more than minimal harm 2025-06-26

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-11

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 2025-07-09

D · Potential for more than minimal harm 2025-05-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-05-29

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 2025-07-09

D · Potential for more than minimal harm 2025-05-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-09

D · Potential for more than minimal harm 2025-04-23

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-23

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 2025-05-08

D · Potential for more than minimal harm 2025-04-23

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-10

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-04-23

D · Potential for more than minimal harm 2025-04-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-23

D · Potential for more than minimal harm 2025-04-01

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 2025-04-09

D · Potential for more than minimal harm 2025-04-01

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-04-09

J · Immediate jeopardy 2025-02-18

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 2025-03-18

F · Potential for more than minimal harm 2025-02-18

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 2025-03-18

E · Potential for more than minimal harm 2025-02-18

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

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 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

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 2025-03-18

D · Potential for more than minimal harm 2025-02-18

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 2025-03-18

D · Potential for more than minimal harm 2025-02-18

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 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

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 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2025-03-18

D · Potential for more than minimal harm 2025-02-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-18

D · Potential for more than minimal harm 2024-12-17

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-12-17

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-26

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-12

D · Potential for more than minimal harm 2024-10-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-11-15

E · Potential for more than minimal harm 2024-10-02

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-11-15

D · Potential for more than minimal harm 2024-09-30

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 2024-10-15

D · Potential for more than minimal harm 2024-08-21

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 2024-09-16

D · Potential for more than minimal harm 2024-08-21

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-21

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-21

F710 · Nursing and Physician Services Deficiencies

Health

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-21

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 2024-09-16

E · Potential for more than minimal harm 2024-05-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-07-02

E · Potential for more than minimal harm 2024-05-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-02

D · Potential for more than minimal harm 2024-05-31

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-02

D · Potential for more than minimal harm 2024-05-31

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 2024-07-02

D · Potential for more than minimal harm 2024-05-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-07-02

D · Potential for more than minimal harm 2024-05-31

F922 · Environmental Deficiencies

Health

Have enough backup water supply for essential areas of the nursing home.

Corrected 2024-07-02

D · Potential for more than minimal harm 2024-03-26

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 2024-04-23

D · Potential for more than minimal harm 2024-03-26

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-02-22

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 2024-02-28

J · Immediate jeopardy 2024-01-19

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 2024-02-28

F · Potential for more than minimal harm 2024-01-19

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 2024-02-28

E · Potential for more than minimal harm 2024-01-19

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 2024-02-28

E · Potential for more than minimal harm 2024-01-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-02-28

E · Potential for more than minimal harm 2024-01-19