Cycle 1
Health 2024-08-29 · Fire 2024-08-29
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Saint Petersburg, FL
Eagle Lake Nursing And Rehab Care Center
1-star overall rating with 1-star inspections with $312,600 in total fines with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1100 66th St N, Saint Petersburg, FL
(727) 345-9331
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Blue Ridge Healthcare
Operator or chain grouping
Approved since
1976-01-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 1 overall / 2 health / 1 staffing / 1 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,153
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.03% · Performance 22.74% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.88% · Performance 9.61% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.58
Baseline 92.86% · Performance 85.53% · Measure score 0.58 · Achievement 0 · Improvement 0.58
Adjusted total nurse staffing
2.58
Baseline 3.07 hours · Performance 3.81 hours · Measure score 2.58 · Achievement 2.58 · Improvement 2.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 11.29% · Lower 95% interval 7.4% |
| Discharge to community | 42.04% |
50.57%
8.5 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 29.55% · Lower 95% interval 29.68% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 57 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 26.67% |
53.69%
27 pts worse
|
Numerator 8 · Denominator 30 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 6 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 1.42% |
| Healthcare-associated infections requiring hospitalization | 9.61% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 19.44% · Lower 95% interval 4.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 1.8% |
42%
40.2 pts worse
|
Numerator 2 · Denominator 111 |
| Discharge function score | 23.33% |
56.45%
33.1 pts worse
|
Numerator 7 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5.71% |
25.2%
19.5 pts worse
|
Numerator 2 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.1 |
2.1
2 pts worse
|
1.9
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 5.5 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.4 |
1.2
4.2 pts worse
|
1.8
3.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.4 · Observed 6.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.4% |
97.8%
20.4 pts worse
|
93.4%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 68.6% · Q2 92.3% · Q3 97.1% · Q4 51.4% · 4Q avg 77.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
99.2%
18.2 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
2.6%
2.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.1% · Q3 5.7% · Q4 5.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
3.7%
1 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 10.7% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 12.7% |
5.9%
6.8 pts worse
|
5.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 3.3% · Q3 10.0% · Q4 15.2% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.3% |
15.7%
31.6 pts worse
|
19.6%
27.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 46.2% · Q3 48.6% · Q4 48.6% · 4Q avg 47.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
9.8%
9 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · 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 | 26.8% |
11.7%
15.1 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.9% |
9.8%
21.1 pts worse
|
14.9%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 36.4% · Q3 28.6% · Q4 35.5% · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.4%
1.5 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.5% · Q3 3.9% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.2% |
0.8%
5.4 pts worse
|
1.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 13.3% · Q3 6.7% · Q4 0.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.4% |
12.5%
0.9 pts worse
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 14.7% · Q3 14.9% · Q4 9.0% · 4Q avg 13.4% |
| Percentage of long-stay residents with pressure ulcers | 12.2% |
5.1%
7.1 pts worse
|
5.1%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 7.1% · Q3 14.7% · Q4 7.5% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 27.4% |
94.3%
66.9 pts worse
|
81.7%
54.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 26.9% · Q4 18.5% · 4Q avg 27.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
9.3%
1 pts worse
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 14.3% · Expected 15.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 19.2% |
94.7%
75.5 pts worse
|
79.7%
60.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 19.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.5% |
26.2%
8.3 pts worse
|
23.9%
10.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.5% · Observed 42.9% · Expected 29.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-08 · Fire 2022-09-08
11 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-03-18 · Fire 2021-03-18
23 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-29
D · Potential for more than minimal harm
2022-09-08
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-09-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-08
D · Potential for more than minimal harm
2021-03-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2021-07-10
Inspection history
Recent health citations
G · Actual harm
2024-09-18
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 2024-11-30
G · Actual harm
2024-09-18
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-09-18
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 2024-11-30
G · Actual harm
2024-08-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-29
G · Actual harm
2024-08-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-08-29
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-09-29
E · Potential for more than minimal harm
2024-08-29
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 2025-01-27
E · Potential for more than minimal harm
2024-08-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-08-29
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 2024-09-29
D · Potential for more than minimal harm
2024-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-08-29
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 2024-11-30
D · Potential for more than minimal harm
2024-08-29
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 2024-09-29
D · Potential for more than minimal harm
2024-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-08-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-08-29
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 2025-01-27
D · Potential for more than minimal harm
2024-08-29
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-29
K · Immediate jeopardy
2023-11-02
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-12-20
K · Immediate jeopardy
2023-11-02
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-02
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 2023-12-20
D · Potential for more than minimal harm
2023-11-02
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 2023-12-20
D · Potential for more than minimal harm
2023-11-02
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 2023-12-20
D · Potential for more than minimal harm
2023-08-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-07
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 2023-09-07
D · Potential for more than minimal harm
2023-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-07
E · Potential for more than minimal harm
2022-09-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-09-08
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 2022-10-08
D · Potential for more than minimal harm
2022-09-08
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 2022-10-08
D · Potential for more than minimal harm
2022-09-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-09-08
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 2022-10-08
D · Potential for more than minimal harm
2022-09-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-08
E · Potential for more than minimal harm
2021-03-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-04-18
E · Potential for more than minimal harm
2021-03-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-04-18
E · Potential for more than minimal harm
2021-03-18
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
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 2021-04-18
D · Potential for more than minimal harm
2021-03-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
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 2021-04-18
D · Potential for more than minimal harm
2021-03-18
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 2021-07-10
D · Potential for more than minimal harm
2021-03-18
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 2021-04-18
D · Potential for more than minimal harm
2021-03-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-04-18
D · Potential for more than minimal harm
2021-03-18
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 2021-04-18
Penalties and ownership
What sits behind the stars
$152,887
2024-08-29
Fine
Fine · fine $152,887
Fine
$159,713
2023-11-02
Fine
Fine · fine $159,713
Fine
Ownership
Eagle Lake Nursing And Rehab Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Bush, Sherry
Operational/Managerial Control · Individual
Najman, Eden
Corporate Officer · Individual
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