Cycle 1
Health 2024-08-05 · Fire 2024-08-05
43 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Hagerstown, MD
Creekside Center For Rehabilitation And Nursing
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $101,178 in total fines with 43 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1183 Luther Drive, Hagerstown, MD
(301) 790-1000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mordechai Weisz
Operator or chain grouping
Approved since
1978-04-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.49% · Performance 23.41% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.12% · Performance 8.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 72.84% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.83 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.54% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 234 · Observed rate 8.55% · Lower 95% interval 7.28% |
| Discharge to community | 42.86% |
50.57%
7.7 pts worse
|
Worse than the National Rate · Eligible stays 267 · Observed rate 37.45% · Lower 95% interval 36.56% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.35% |
95.27%
4.1 pts better
|
Numerator 154 · Denominator 155 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 155 |
| Discharge self-care score | 50.57% |
53.69%
3.1 pts worse
|
Numerator 44 · Denominator 87 |
| Discharge mobility score | 44.83% |
50.94%
6.1 pts worse
|
Numerator 39 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 9.68% |
2.29%
7.4 pts worse
|
Numerator 15 · Denominator 155 · Adjusted rate 6.8% |
| Healthcare-associated infections requiring hospitalization | 8.96% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 10.37% · Lower 95% interval 6.27% |
| Staff COVID-19 vaccination coverage | 1.79% |
8.2%
6.4 pts worse
|
Numerator 1 · Denominator 56 |
| Staff flu vaccination coverage | 74.03% |
42%
32 pts better
|
Numerator 57 · Denominator 77 |
| Discharge function score | 48.28% |
56.45%
8.2 pts worse
|
Numerator 42 · Denominator 87 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 79 · Denominator 79 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 3.03% |
25.2%
22.2 pts worse
|
Numerator 2 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.3
1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.2
1.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
91.9%
2.4 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 98.4% · Q3 81.0% · Q4 83.1% · 4Q avg 89.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
96.6%
1.4 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
2.3%
1.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.9% · Q3 1.6% · Q4 1.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 57.9% |
21.4%
36.5 pts worse
|
11.4%
46.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 68.5% · Q2 93.4% · Q3 28.8% · Q4 22.9% · 4Q avg 57.9% |
| Percentage of long-stay residents who lose too much weight | 11.7% |
5.7%
6 pts worse
|
5.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.7% · Q3 22.0% · Q4 7.7% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
16.1%
11.3 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 24.1% · Q3 27.1% · Q4 32.7% · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
15.3%
5 pts worse
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 23.3% · Q3 18.9% · Q4 19.2% · 4Q avg 20.3% · 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 | 16.4% |
26.6%
10.2 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
22.9%
14.7 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 6.4% · Q3 9.4% · Q4 14.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.5%
0.2 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 1.6% · Q4 1.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
25.4%
2.3 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 29.0% · Q3 25.4% · Q4 35.7% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.3%
0.8 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.2% · Q3 4.8% · Q4 3.4% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.9% |
78.4%
23.5 pts worse
|
81.7%
26.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.1% · Q2 65.4% · Q3 47.1% · Q4 58.0% · 4Q avg 54.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
9.9%
6.7 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 18.5% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.0% |
80.6%
18.6 pts worse
|
79.7%
17.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
21.2%
4.5 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 19.4% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-25 · Fire 2019-07-25
42 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-02-05 · Fire 2018-02-05
24 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-08-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-08-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-08-05
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 2024-10-09
F · Potential for more than minimal harm
2024-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-08-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-04
D · Potential for more than minimal harm
2018-02-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-04-11
B · Minimal harm
2018-02-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-04-11
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-23
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 2025-11-24
G · Actual harm
2025-10-17
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 2025-02-04
E · Potential for more than minimal harm
2025-10-17
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 2025-12-03
D · Potential for more than minimal harm
2025-10-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-21
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 2025-03-31
D · Potential for more than minimal harm
2025-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-31
J · Immediate jeopardy
2024-08-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-11-22
J · Immediate jeopardy
2024-08-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-22
G · Actual harm
2024-08-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-08-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-08-05
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 2024-10-08
F · Potential for more than minimal harm
2024-08-05
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 2024-11-22
F · Potential for more than minimal harm
2024-08-05
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-08-05
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 2024-10-07
E · Potential for more than minimal harm
2024-08-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-08-05
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 2024-11-22
E · Potential for more than minimal harm
2024-08-05
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 2024-10-08
E · Potential for more than minimal harm
2024-08-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
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 2024-11-22
D · Potential for more than minimal harm
2024-08-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
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 2024-10-08
D · Potential for more than minimal harm
2024-08-05
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 2024-11-22
D · Potential for more than minimal harm
2024-08-05
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 2024-11-22
D · Potential for more than minimal harm
2024-08-05
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
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 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-08-05
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 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
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 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-08-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
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 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-08
J · Immediate jeopardy
2019-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-25
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-25
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 2019-09-25
E · Potential for more than minimal harm
2019-07-25
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 2019-11-19
E · Potential for more than minimal harm
2019-07-25
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 2019-09-25
E · Potential for more than minimal harm
2019-07-25
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 2019-11-19
E · Potential for more than minimal harm
2019-07-25
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 2019-09-25
E · Potential for more than minimal harm
2019-07-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-19
E · Potential for more than minimal harm
2019-07-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-19
E · Potential for more than minimal harm
2019-07-25
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-25
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 2019-11-19
E · Potential for more than minimal harm
2019-07-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-25
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 2019-09-25
D · Potential for more than minimal harm
2019-07-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-25
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 2019-09-25
D · Potential for more than minimal harm
2019-07-25
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 2019-09-25
D · Potential for more than minimal harm
2019-07-25
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 2019-09-25
D · Potential for more than minimal harm
2019-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-25
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 2019-09-25
D · Potential for more than minimal harm
2019-07-25
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 2019-09-25
D · Potential for more than minimal harm
2019-07-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2019-09-25
C · Minimal harm
2019-07-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-11-19
B · Minimal harm
2019-07-25
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-09-25
F · Potential for more than minimal harm
2018-02-05
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
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 2018-03-28
E · Potential for more than minimal harm
2018-02-05
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 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
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 2018-03-28
E · Potential for more than minimal harm
2018-02-05
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 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-03-28
E · Potential for more than minimal harm
2018-02-05
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 2018-03-28
D · Potential for more than minimal harm
2018-02-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-03-28
D · Potential for more than minimal harm
2018-02-05
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 2018-03-28
D · Potential for more than minimal harm
2018-02-05
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 2018-03-28
D · Potential for more than minimal harm
2018-02-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2018-03-28
D · Potential for more than minimal harm
2018-02-05
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2018-03-28
D · Potential for more than minimal harm
2018-02-05
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 2018-03-28
D · Potential for more than minimal harm
2018-02-05
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 2018-03-28
D · Potential for more than minimal harm
2018-02-05
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2018-03-28
D · Potential for more than minimal harm
2018-02-05
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2018-03-28
D · Potential for more than minimal harm
2018-02-05
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 2018-03-28
C · Minimal harm
2018-02-05
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 2018-03-28
Penalties and ownership
What sits behind the stars
$101,178
2024-08-05
Fine
Fine · fine $101,178
Fine
Ownership
Weisz, Mordechai
5% Or Greater Direct Ownership Interest · Individual
Elebiary, Ahmed
Operational/Managerial Control · Individual
Lions Healthcare Management LLC
Operational/Managerial Control · Organization
Truslow, Cynthia
Operational/Managerial Control · Individual
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