Crownsville, MD

Fairfield Nursing & Rehabilitation Center

2-star overall rating with 2-star inspections with $51,597 in total fines with 33 recent health deficiencies with 31 fire-safety deficiencies in the latest cycle

1454 Fairfield Loop Road, Crownsville, MD

(410) 923-6820

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Fundamental Healthcare

Operator or chain grouping

Approved since

1991-11-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

69 facilities

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

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.56

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

0.90

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.74

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.20

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

1.46

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

2.84

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

0.41

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.31

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

19%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,310

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

Performance score

44.94

Composite VBP score used to determine payment impact.

Payment multiplier

0.9981

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.63% · Performance 22.41% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

6.42

Baseline 7.23% · Performance 5.92% · Measure score 6.42 · Achievement 6.42 · Improvement 5.38

Total nurse turnover

Baseline 27.08% · Performance 20.46% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

1.56

Baseline 3.55 hours · Performance 3.52 hours · Measure score 1.56 · Achievement 1.56 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	14%	10.72% 3.3 pts worse	Worse than the National Rate · Eligible stays 393 · Observed rate 14.25% · Lower 95% interval 11.83%
Discharge to community	67.83%	50.57% 17.3 pts better	Better than the National Rate · Eligible stays 362 · Observed rate 63.54% · Lower 95% interval 62.42%
Medicare spending per beneficiary	0.79	1.02 0.2 pts better
Drug regimen review with follow-up	98.09%	95.27% 2.8 pts better	Numerator 205 · Denominator 209
Falls with major injury	0.48%	0.77% 0.3 pts better	Numerator 1 · Denominator 209
Discharge self-care score	43.29%	53.69% 10.4 pts worse	Numerator 71 · Denominator 164
Discharge mobility score	43.29%	50.94% 7.6 pts worse	Numerator 71 · Denominator 164
Pressure ulcers or injuries, new or worsened	6.7%	2.29% 4.4 pts worse	Numerator 14 · Denominator 209 · Adjusted rate 6.2%
Healthcare-associated infections requiring hospitalization	5.92%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 208 · Observed rate 4.33% · Lower 95% interval 3.97%
Staff COVID-19 vaccination coverage	1.18%	8.2% 7 pts worse	Numerator 1 · Denominator 85
Staff flu vaccination coverage	89.02%	42% 47 pts better	Numerator 73 · Denominator 82
Discharge function score	40.85%	56.45% 15.6 pts worse	Numerator 67 · Denominator 164
Transfer of health information to provider	92.31%	95.95% 3.6 pts worse	Numerator 48 · Denominator 52
Transfer of health information to patient	90.84%	96.28% 5.4 pts worse	Numerator 119 · Denominator 131
Resident COVID-19 vaccinations up to date	20.43%	25.2% 4.8 pts worse	Numerator 19 · Denominator 93

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	1.3 About the same	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.2 About the same	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	82.5%	91.9% 9.4 pts worse	93.4% 10.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 75.0% · Q3 82.4% · Q4 83.0% · 4Q avg 82.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.2%	96.6% 1.6 pts better	95.5% 2.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2%
Percentage of long-stay residents experiencing one or more falls with major injury	1.4%	2.3% 0.9 pts better	3.3% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 3.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	21.4% 19.2 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	4.0%	5.7% 1.7 pts better	5.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.0% · Q3 4.0% · Q4 4.0% · 4Q avg 4.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.2%	16.1% 0.9 pts better	19.6% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 14.0% · Q3 20.0% · Q4 18.0% · 4Q avg 15.2%
Percentage of long-stay residents who received an antipsychotic medication	22.1%	15.3% 6.8 pts worse	16.7% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 19.4% · Q3 21.6% · Q4 27.9% · 4Q avg 22.1% · 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	33.3%	26.6% 6.7 pts worse	16.3% 17 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.7%	22.9% 0.2 pts better	14.9% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 16.7% · Q3 24.4% · Q4 6.1% · 4Q avg 22.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.7% 0.1 pts worse	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% · 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 3.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.0%	25.4% 0.6 pts worse	19.8% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 25.4% · Q3 24.4% · Q4 28.3% · 4Q avg 26.0%
Percentage of long-stay residents with pressure ulcers	7.4%	6.3% 1.1 pts worse	5.1% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.0% · Q3 8.7% · Q4 9.7% · 4Q avg 7.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.9%	78.4% 10.5 pts better	81.7% 7.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 92.5% · Q3 87.7% · Q4 80.0% · 4Q avg 88.9%
Percentage of short-stay residents who had an outpatient emergency department visit	8.7%	9.9% 1.2 pts better	12.0% 3.3 pts better	Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.1% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.2%	1.3% 1.9 pts worse	1.6% 1.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.5% · Q3 3.7% · Q4 2.1% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.8%	80.6% 9.2 pts better	79.7% 10.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.9%	21.2% 1.7 pts worse	23.9% 1 pts better	Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 20.2% · Expected 21.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-03 · Fire 2024-05-03

33 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

31 fire-safety deficiencies

Top issue: Smoke (10 deficiencies)

Cycle 2 Health 2019-05-03 · Fire 2019-05-03

2 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2017-12-20 · Fire 2017-12-20

15 health deficiencies

Top issue: Resident Assessment and Care Planning (5 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 2024-05-03

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-09

F · Potential for more than minimal harm 2024-05-03

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-05-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-05-03

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-08-09

F · Potential for more than minimal harm 2024-05-03

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 2024-08-01

F · Potential for more than minimal harm 2024-05-03

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2024-08-28

F · Potential for more than minimal harm 2024-05-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-08-28

E · Potential for more than minimal harm 2024-05-03

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-08-01

E · Potential for more than minimal harm 2024-05-03

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 2024-08-01

E · Potential for more than minimal harm 2024-05-03

K261 · Egress Deficiencies

Fire Safety

Have properly spaced exits within rooms.

Corrected 2024-08-28

E · Potential for more than minimal harm 2024-05-03

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-08-01

E · Potential for more than minimal harm 2024-05-03

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-08-28

E · Potential for more than minimal harm 2024-05-03

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2024-08-28

E · Potential for more than minimal harm 2024-05-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-01

E · Potential for more than minimal harm 2024-05-03

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-01

E · Potential for more than minimal harm 2024-05-03

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-08-01

D · Potential for more than minimal harm 2024-05-03

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-05-03

K251 · Egress Deficiencies

Fire Safety

Conform to length requirements for dead end corridors.

Corrected 2024-08-01

D · Potential for more than minimal harm 2024-05-03

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 2024-08-01

D · Potential for more than minimal harm 2024-05-03

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-08-09

D · Potential for more than minimal harm 2024-05-03

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-08-01

D · Potential for more than minimal harm 2024-05-03

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-08-01

D · Potential for more than minimal harm 2024-05-03

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-05-03

K525 · Services Deficiencies

Fire Safety

Enure that solid fuel-burning fireplaces are not in patient sleeping areas.

Corrected 2024-08-01

F · Potential for more than minimal harm 2019-05-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2019-06-10

D · Potential for more than minimal harm 2019-05-03

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-06-10

D · Potential for more than minimal harm 2019-05-03

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2019-06-10

C · Minimal harm 2019-05-03

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2019-06-10

C · Minimal harm 2019-05-03

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-06-10

B · Minimal harm 2019-05-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2019-06-10

F · Potential for more than minimal harm 2017-12-20

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2018-02-02

D · Potential for more than minimal harm 2017-12-20

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2018-02-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-17

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-10-20

E · Potential for more than minimal harm 2025-09-17

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-20

E · Potential for more than minimal harm 2025-09-17

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-10-20

E · Potential for more than minimal harm 2025-09-17

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-17

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

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 2025-10-20

D · Potential for more than minimal harm 2025-09-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-17

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 2025-10-20

C · Minimal harm 2025-09-17

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-10-20

E · Potential for more than minimal harm 2024-05-03

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 2024-06-25

E · Potential for more than minimal harm 2024-05-03

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 2024-06-25

E · Potential for more than minimal harm 2024-05-03

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 2024-06-25

E · Potential for more than minimal harm 2024-05-03

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

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 2024-06-25

D · Potential for more than minimal harm 2024-05-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-25

G · Actual harm 2024-01-30

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 2024-01-31

D · Potential for more than minimal harm 2024-01-30

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 2024-02-21

D · Potential for more than minimal harm 2024-01-30

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-01-31

D · Potential for more than minimal harm 2024-01-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-31

E · Potential for more than minimal harm 2019-05-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-06-16

D · Potential for more than minimal harm 2019-05-03

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2019-06-16

E · Potential for more than minimal harm 2017-12-20

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 2018-01-22

D · Potential for more than minimal harm 2017-12-20

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 2018-01-22

D · Potential for more than minimal harm 2017-12-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-01-22

D · Potential for more than minimal harm 2017-12-20

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 2018-01-22

D · Potential for more than minimal harm 2017-12-20

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 2018-01-22

D · Potential for more than minimal harm 2017-12-20

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2018-01-22

D · Potential for more than minimal harm 2017-12-20

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 2018-01-22

D · Potential for more than minimal harm 2017-12-20

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2018-01-22

D · Potential for more than minimal harm 2017-12-20

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 2018-01-22

D · Potential for more than minimal harm 2017-12-20

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2018-01-22

D · Potential for more than minimal harm 2017-12-20

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 2018-01-22

Penalties and ownership