Cycle 1
Health 2025-08-13 · Fire 2023-09-28
41 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Chestertown, MD
Chestertown Nursing And Rehab
1-star overall rating with 1-star inspections with abuse icon flag with $3,418 in total fines with 41 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
415 Morgnec Road, Chestertown, MD
(410) 778-1900
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Key Health Management
Operator or chain grouping
Approved since
1994-09-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 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
0.67
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
2.75
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,590
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.46
Baseline 17.36% · Performance 18.44% · Measure score 6.46 · Achievement 6.46 · Improvement 0
Healthcare-associated infections
0
Baseline 7.60% · Performance 8.20% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.48
Baseline 73.33% · Performance 63.74% · Measure score 1.48 · Achievement 0 · Improvement 1.48
Adjusted total nurse staffing
0
Baseline 2.86 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.17% |
10.72%
3.4 pts worse
|
Worse than the National Rate · Eligible stays 137 · Observed rate 19.71% · Lower 95% interval 11.03% |
| Discharge to community | 41.14% |
50.57%
9.4 pts worse
|
Worse than the National Rate · Eligible stays 107 · Observed rate 34.58% · Lower 95% interval 32.05% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 100 · Denominator 100 |
| Falls with major injury | 2% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 100 |
| Discharge self-care score | 60.26% |
53.69%
6.6 pts better
|
Numerator 47 · Denominator 78 |
| Discharge mobility score | 58.97% |
50.94%
8 pts better
|
Numerator 46 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 3% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 100 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 8.2% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 9.76% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 2.27% |
8.2%
5.9 pts worse
|
Numerator 3 · Denominator 132 |
| Staff flu vaccination coverage | 49.62% |
42%
7.6 pts better
|
Numerator 66 · Denominator 133 |
| Discharge function score | 60.26% |
56.45%
3.8 pts better
|
Numerator 47 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 1.54% |
25.2%
23.7 pts worse
|
Numerator 1 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.3
0.9 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 51.9% |
91.9%
40 pts worse
|
93.4%
41.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.5% · Q2 50.7% · Q3 50.7% · Q4 50.0% · 4Q avg 51.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
96.6%
0.9 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.3%
0.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.7% · Q4 1.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 51.1% |
21.4%
29.7 pts worse
|
11.4%
39.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 52.1% · Q3 52.8% · Q4 52.8% · 4Q avg 51.1% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
5.7%
3.6 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 9.6% · Q3 10.8% · Q4 6.5% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
16.1%
2.4 pts worse
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 15.1% · Q3 18.7% · Q4 19.5% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.8% |
15.3%
11.5 pts worse
|
16.7%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 32.7% · Q3 24.1% · Q4 17.5% · 4Q avg 26.8% · 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 | 29.4% |
26.6%
2.8 pts worse
|
16.3%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.7% · Q2 19.9% · Q3 26.2% · Q4 3.7% · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
22.9%
3.1 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.7% · Q2 27.7% · Q3 27.3% · Q4 5.6% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.7%
1 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.8% · Q3 1.0% · Q4 0.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.5%
0.9 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.7% · Q3 2.7% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.3% |
25.4%
4.9 pts worse
|
19.8%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 34.3% · Q3 28.6% · Q4 30.9% · 4Q avg 30.3% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
6.3%
About the same
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.7% · Q3 7.8% · Q4 3.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 12.1% |
78.4%
66.3 pts worse
|
81.7%
69.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 16.4% · Q3 11.8% · Q4 12.3% · 4Q avg 12.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
9.9%
4.4 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 13.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.3%
2.9 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.5% · Q3 2.4% · Q4 6.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 26.7% |
80.6%
53.9 pts worse
|
79.7%
53 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 26.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.0% |
21.2%
10.2 pts better
|
23.9%
12.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 11.7% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2019-02-15
29 health deficiencies
Top issue: Resident Rights (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-02-15 · Fire 2017-10-19
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-09-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-12
F · Potential for more than minimal harm
2023-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-09-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-09-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-09-28
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 2024-01-17
F · Potential for more than minimal harm
2023-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-09-28
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 2024-02-12
E · Potential for more than minimal harm
2023-09-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-09-28
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-09-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-09-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-17
F · Potential for more than minimal harm
2019-02-15
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-06-14
F · Potential for more than minimal harm
2019-02-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-14
F · Potential for more than minimal harm
2019-02-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-06-14
F · Potential for more than minimal harm
2019-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-14
E · Potential for more than minimal harm
2019-02-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-02-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-02-15
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 2019-06-14
F · Potential for more than minimal harm
2017-10-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-01-07
F · Potential for more than minimal harm
2017-10-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2017-12-28
D · Potential for more than minimal harm
2017-10-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-01-12
D · Potential for more than minimal harm
2017-10-19
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 2018-01-07
D · Potential for more than minimal harm
2017-10-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-01-07
D · Potential for more than minimal harm
2017-10-19
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-01-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-13
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 2025-10-01
F · Potential for more than minimal harm
2025-08-13
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 2025-10-01
F · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-08-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
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 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-13
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-10-01
F · Potential for more than minimal harm
2023-09-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-04
F · Potential for more than minimal harm
2023-09-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-09-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-09-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-09-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
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 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
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 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
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 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
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 2023-12-04
D · Potential for more than minimal harm
2023-09-28
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 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-04
D · Potential for more than minimal harm
2019-02-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-02-15
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-02-15
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 2019-04-15
D · Potential for more than minimal harm
2019-02-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-02-15
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 2019-04-15
D · Potential for more than minimal harm
2019-02-15
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 2019-04-15
D · Potential for more than minimal harm
2019-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-02-15
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 2019-04-15
D · Potential for more than minimal harm
2019-02-15
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 2019-04-15
Penalties and ownership
What sits behind the stars
$3,418
2024-01-22
Fine
Fine · fine $3,418
Fine
Ownership
Md4 Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Hershey, Theresa
Operational/Managerial Control · Individual
Hirth, Yechiel
Operational/Managerial Control · Individual
Hirth, Yechiel
Corporate Officer · Individual
Howard, Daniel
Operational/Managerial Control · Individual
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