Waterbury, CT

Cheshire House Health Care Facility & Rehab Center

2-star overall rating with 2-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

3396 E Main Street, Waterbury, CT

(203) 754-2161

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ryders Health Management

Operator or chain grouping

Approved since

1992-02-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 2 overall / 2 health / 4 staffing / 2 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

0.63

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.24

Licensed practical nurse staffing · state 0.84 · national 0.87

Aide hours / resident day

2.34

Nurse aide staffing · state 2.28 · national 2.35

Total nurse hours

4.21

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.87

RN + LPN hours · state 1.54 · national 1.54

Weekend hours

3.69

Weekend nurse staffing · state 3.41 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.66

CMS adjusted RN staffing hours

Adjusted total hours

4.45

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,005

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

Performance score

41.80

Composite VBP score used to determine payment impact.

Payment multiplier

0.9947

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.35

Baseline 24.29% · Performance 21.50% · Measure score 3.35 · Achievement 0 · Improvement 3.35

Healthcare-associated infections

3.91

Baseline 7.36% · Performance 6.67% · Measure score 3.91 · Achievement 3.91 · Improvement 2.42

Total nurse turnover

5.73

Baseline 43.21% · Performance 40.28% · Measure score 5.73 · Achievement 5.73 · Improvement 1.10

Adjusted total nurse staffing

3.74

Baseline 3.88 hours · Performance 4.14 hours · Measure score 3.74 · Achievement 3.74 · Improvement 0.88

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.37%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 169 · Observed rate 9.47% · Lower 95% interval 7.25%
Discharge to community	61.62%	50.57% 11 pts better	Better than the National Rate · Eligible stays 169 · Observed rate 60.36% · Lower 95% interval 53.84%
Medicare spending per beneficiary	0.92	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 80 · Denominator 80
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 80
Discharge self-care score	49.15%	53.69% 4.5 pts worse	Numerator 29 · Denominator 59
Discharge mobility score	55.93%	50.94% 5 pts better	Numerator 33 · Denominator 59
Pressure ulcers or injuries, new or worsened	2.5%	2.29% 0.2 pts worse	Numerator 2 · Denominator 80 · Adjusted rate 2.34%
Healthcare-associated infections requiring hospitalization	6.67%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 78 · Observed rate 5.13% · Lower 95% interval 4.08%
Staff COVID-19 vaccination coverage	4.73%	8.2% 3.5 pts worse	Numerator 7 · Denominator 148
Staff flu vaccination coverage	31.17%	42% 10.8 pts worse	Numerator 48 · Denominator 154
Discharge function score	57.63%	56.45% 1.2 pts better	Numerator 34 · Denominator 59
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 54 · Denominator 54
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	5.88%	25.2% 19.3 pts worse	Numerator 2 · Denominator 34

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.4	2.1 1.3 pts worse	1.9 1.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.1 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	1.5 0.5 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	53.0%	87.5% 34.5 pts worse	93.4% 40.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 51.9% · Q2 50.0% · Q3 52.7% · Q4 57.4% · 4Q avg 53.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	73.3%	93.5% 20.2 pts worse	95.5% 22.2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 73.3%
Percentage of long-stay residents experiencing one or more falls with major injury	1.8%	3.4% 1.6 pts better	3.3% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	17.1% 17.1 pts better	11.4% 11.4 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 who lose too much weight	6.9%	6.4% 0.5 pts worse	5.4% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 9.6% · Q3 7.8% · Q4 2.0% · 4Q avg 6.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.3%	17.3% 7 pts worse	19.6% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 26.9% · Q3 29.4% · Q4 22.0% · 4Q avg 24.3%
Percentage of long-stay residents who received an antipsychotic medication	24.3%	19.4% 4.9 pts worse	16.7% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 26.2% · Q3 22.5% · Q4 18.6% · 4Q avg 24.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	30.2%	18.1% 12.1 pts worse	16.3% 13.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 54.0% · Q2 41.2% · Q3 9.1% · Q4 10.7% · 4Q avg 30.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	29.8%	18.4% 11.4 pts worse	14.9% 14.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 52.2% · Q2 30.0% · Q3 17.0% · Q4 20.8% · 4Q avg 29.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.9% 0.2 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	1.7% 1.1 pts worse	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 1.8% · Q3 0.0% · Q4 1.9% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	31.4%	24.8% 6.6 pts worse	19.8% 11.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 31.5% · Q3 29.0% · Q4 31.5% · 4Q avg 31.4%
Percentage of long-stay residents with pressure ulcers	6.5%	4.4% 2.1 pts worse	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.6% · Q3 6.8% · Q4 6.3% · 4Q avg 6.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	23.7%	70.5% 46.8 pts worse	81.7% 58 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 17.5% · Q3 28.1% · Q4 33.6% · 4Q avg 23.7%
Percentage of short-stay residents who had an outpatient emergency department visit	7.1%	11.1% 4 pts better	12.0% 4.9 pts better	Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.9% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	1.5% 0.1 pts worse	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.6% · Q4 2.7% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	18.1%	69.7% 51.6 pts worse	79.7% 61.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 18.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.1%	25.0% 6.1 pts worse	23.9% 7.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 31.9% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-22 · Fire 2025-04-22

16 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

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

Cycle 2 Health 2023-04-28 · Fire 2023-04-28

27 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2021-05-27 · Fire 2021-05-27

12 health deficiencies

Top issue: Resident Rights (5 deficiencies)

4 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-04-22

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2025-05-26

D · Potential for more than minimal harm 2025-04-22

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 2025-04-18

D · Potential for more than minimal harm 2025-04-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-05-26

D · Potential for more than minimal harm 2025-04-22

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-05-26

D · Potential for more than minimal harm 2025-04-22

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2025-04-18

F · Potential for more than minimal harm 2023-04-28

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-06-08

D · Potential for more than minimal harm 2023-04-28

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 2023-06-08

D · Potential for more than minimal harm 2023-04-28

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-06-08

D · Potential for more than minimal harm 2023-04-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-08

D · Potential for more than minimal harm 2023-04-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-06-08

D · Potential for more than minimal harm 2021-05-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-07-14

D · Potential for more than minimal harm 2021-05-27

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2021-07-14

D · Potential for more than minimal harm 2021-05-27

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2021-07-14

D · Potential for more than minimal harm 2021-05-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-07-14

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-20

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 2025-12-01

E · Potential for more than minimal harm 2025-04-22

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 2025-06-20

E · Potential for more than minimal harm 2025-04-22

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-04-22

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-04-22

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-04-22

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-04-22

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-04-22

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 2025-06-20

D · Potential for more than minimal harm 2025-04-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-04-22

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 2025-06-20

D · Potential for more than minimal harm 2025-04-22

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-04-22

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-04-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-20

B · Minimal harm 2025-04-22

F584 · Resident Rights Deficiencies

Health

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

Corrected 2025-06-20

B · Minimal harm 2025-04-22

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-06-20

B · Minimal harm 2025-04-22

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-02-24

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-10

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 2025-03-21

D · Potential for more than minimal harm 2025-01-09

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-02-20

D · Potential for more than minimal harm 2025-01-09

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-02-20

D · Potential for more than minimal harm 2025-01-09

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-02-20

D · Potential for more than minimal harm 2024-11-20

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-11-20

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-11-20

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2024-12-30

C · Minimal harm 2024-11-20

F836 · Administration Deficiencies

Health

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Corrected 2024-12-30

D · Potential for more than minimal harm 2023-08-01

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 2023-09-12

D · Potential for more than minimal harm 2023-08-01

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-09-12

E · Potential for more than minimal harm 2023-04-28

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-04-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-04-28

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-04-28

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F584 · Resident Rights Deficiencies

Health

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

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

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 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-04-28

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2023-06-09

B · Minimal harm 2023-04-28

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 2023-06-09

B · Minimal harm 2023-04-28

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-06-09

B · Minimal harm 2023-04-28

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2023-06-09

B · Minimal harm 2023-04-28

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 2023-06-09

F · Potential for more than minimal harm 2021-05-27

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 2021-07-03

D · Potential for more than minimal harm 2021-05-27

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 2021-07-03

D · Potential for more than minimal harm 2021-05-27

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2021-07-03

D · Potential for more than minimal harm 2021-05-27

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2021-07-03

D · Potential for more than minimal harm 2021-05-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-07-03

D · Potential for more than minimal harm 2021-05-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-07-03

C · Minimal harm 2021-05-27

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2021-07-03

C · Minimal harm 2021-05-27

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 2021-07-03

B · Minimal harm 2021-05-27

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 2021-07-03

B · Minimal harm 2021-05-27

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 2021-07-03

Penalties and ownership