Cycle 1
Health 2025-10-09 · Fire 2025-10-09
66 health deficiencies
Top issue: Quality of Life and Care (18 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Elkton, MD
Elkton Nursing And Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with $30,742 in total fines with 66 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1 Price Drive, Elkton, MD
(410) 398-6474
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
182
Certified beds
Average residents
170
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1994-11-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 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
0.47
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,478
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.87% · Performance 22.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.59% · Performance 9.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.82
Baseline 70.86% · Performance 46.40% · Measure score 4.82 · Achievement 4.23 · Improvement 4.82
Adjusted total nurse staffing
0
Baseline 2.88 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 427 · Observed rate 12.65% · Lower 95% interval 8.97% |
| Discharge to community | 48.8% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 452 · Observed rate 39.16% · Lower 95% interval 42.87% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 91.64% |
95.27%
3.6 pts worse
|
Numerator 285 · Denominator 311 |
| Falls with major injury | 0.64% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 311 |
| Discharge self-care score | 52.17% |
53.69%
1.5 pts worse
|
Numerator 72 · Denominator 138 |
| Discharge mobility score | 51.45% |
50.94%
0.5 pts better
|
Numerator 71 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 1.94% |
2.29%
0.4 pts better
|
Numerator 6 · Denominator 310 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 9.83% |
7.12%
2.7 pts worse
|
Worse than the National Rate · Eligible stays 263 · Observed rate 11.79% · Lower 95% interval 7.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 125 |
| Staff flu vaccination coverage | 74.73% |
42%
32.7 pts better
|
Numerator 136 · Denominator 182 |
| Discharge function score | 62.32% |
56.45%
5.9 pts better
|
Numerator 86 · Denominator 138 |
| Transfer of health information to provider | 86.3% |
95.95%
9.7 pts worse
|
Numerator 126 · Denominator 146 |
| Transfer of health information to patient | 96.33% |
96.28%
About the same
|
Numerator 105 · Denominator 109 |
| Resident COVID-19 vaccinations up to date | 2.14% |
25.2%
23.1 pts worse
|
Numerator 3 · Denominator 140 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.3
0.9 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
91.9%
2.9 pts worse
|
93.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.3% · Q2 91.0% · Q3 91.9% · Q4 91.9% · 4Q avg 89.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
96.6%
2.7 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
2.3%
0.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 1.5% · Q4 1.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 48.8% |
21.4%
27.4 pts worse
|
11.4%
37.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.4% · Q2 51.7% · Q3 47.1% · Q4 49.2% · 4Q avg 48.8% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.7%
0.5 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.8% · Q3 4.2% · Q4 7.4% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
16.1%
3.5 pts worse
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 19.5% · Q3 18.9% · Q4 18.0% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
15.3%
5.2 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 16.1% · Q3 22.1% · Q4 21.8% · 4Q avg 20.5% · 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 | 13.7% |
26.6%
12.9 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 22.3% · Q3 23.7% · Q4 7.9% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
22.9%
4.4 pts better
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 18.3% · Q3 20.3% · Q4 13.9% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.5%
0.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.5% |
25.4%
5.1 pts worse
|
19.8%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 35.3% · Q3 31.2% · Q4 26.0% · 4Q avg 30.5% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
6.3%
1.1 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.6% · Q3 5.1% · Q4 4.5% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
78.4%
14.7 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 94.3% · Q3 92.8% · Q4 88.6% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
9.9%
1 pts worse
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 11.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 1.2% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
80.6%
14.2 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
21.2%
0.5 pts worse
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 23.0% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-20 · Fire 2023-11-20
49 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
19 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2021-08-13 · Fire 2021-08-13
58 health deficiencies
Top issue: Quality of Life and Care (16 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-01
E · Potential for more than minimal harm
2025-10-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-01
E · Potential for more than minimal harm
2025-10-09
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 2026-01-01
E · Potential for more than minimal harm
2025-10-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-01-01
E · Potential for more than minimal harm
2025-10-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-01
E · Potential for more than minimal harm
2025-10-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-10-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2026-01-01
F · Potential for more than minimal harm
2023-11-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
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 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
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 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
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 2023-12-15
D · Potential for more than minimal harm
2023-11-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-20
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-20
K909 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum piping is labeled.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-15
F · Potential for more than minimal harm
2021-08-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-13
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-08-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2021-09-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-12
D · Potential for more than minimal harm
2026-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-12
D · Potential for more than minimal harm
2026-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-12
D · Potential for more than minimal harm
2026-01-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-12
D · Potential for more than minimal harm
2026-01-29
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2026-02-12
G · Actual harm
2025-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-02
G · Actual harm
2025-10-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-02
F · Potential for more than minimal harm
2025-10-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-10-09
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-10-09
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 2025-12-02
F · Potential for more than minimal harm
2025-10-09
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-12-02
F · Potential for more than minimal harm
2025-10-09
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 2025-12-02
F · Potential for more than minimal harm
2025-10-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-02
F · Potential for more than minimal harm
2025-10-09
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 2025-12-02
F · Potential for more than minimal harm
2025-10-09
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 2025-12-02
F · Potential for more than minimal harm
2025-10-09
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-12-02
F · Potential for more than minimal harm
2025-10-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-12-02
E · Potential for more than minimal harm
2025-10-09
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 2025-12-02
E · Potential for more than minimal harm
2025-10-09
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 2025-12-02
E · Potential for more than minimal harm
2025-10-09
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 2025-12-02
E · Potential for more than minimal harm
2025-10-09
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2026-02-12
E · Potential for more than minimal harm
2025-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-12
E · Potential for more than minimal harm
2025-10-09
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 2025-12-02
E · Potential for more than minimal harm
2025-10-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-10-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
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 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-02-12
D · Potential for more than minimal harm
2025-10-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
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 2025-12-02
D · Potential for more than minimal harm
2025-10-09
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 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F774 · Administration Deficiencies
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
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 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-10-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-02
E · Potential for more than minimal harm
2025-07-02
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 2025-08-16
E · Potential for more than minimal harm
2025-07-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-16
E · Potential for more than minimal harm
2025-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-16
E · Potential for more than minimal harm
2025-07-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-16
E · Potential for more than minimal harm
2025-07-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
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 2025-08-16
C · Minimal harm
2025-07-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-16
F · Potential for more than minimal harm
2023-11-20
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 2024-01-17
F · Potential for more than minimal harm
2023-11-20
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-11-20
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 2024-01-17
F · Potential for more than minimal harm
2023-11-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-11-20
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-11-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-11-20
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 2024-01-17
F · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
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 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-20
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 2024-01-17
C · Minimal harm
2023-11-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-17
J · Immediate jeopardy
2023-08-25
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 2023-08-25
F · Potential for more than minimal harm
2023-06-26
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 2023-08-01
F · Potential for more than minimal harm
2023-06-26
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 2023-08-01
E · Potential for more than minimal harm
2023-06-26
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 2023-08-01
E · Potential for more than minimal harm
2023-06-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-26
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 2023-08-01
C · Minimal harm
2023-06-26
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-08-01
C · Minimal harm
2023-06-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-01
E · Potential for more than minimal harm
2021-08-13
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 2021-09-17
E · Potential for more than minimal harm
2021-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-13
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 2021-09-17
E · Potential for more than minimal harm
2021-08-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
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 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-17
Penalties and ownership
What sits behind the stars
$9,110
2025-10-09
Fine
Fine · fine $9,110
Fine
$16,559
2025-10-09
Fine
Fine · fine $16,559
Fine
$0
2025-10-09
Payment Denial
Payment Denial · denial start 2026-01-09 · 34 days
34 day denial
$5,073
2023-08-25
Fine
Fine · fine $5,073
Fine
Ownership
Elkton Health Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Kohn, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Birnbaum, Israel
5% Or Greater Indirect Ownership Interest · Individual
Netzer, Michele
5% Or Greater Indirect Ownership Interest · Individual
Rma Equity LLC
5% Or Greater Indirect Ownership Interest · Organization
Birnbaum, Israel
W-2 Managing Employee · Individual
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2-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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