Cycle 1
Health 2024-10-28 · Fire 2024-10-28
31 health deficiencies
Top issue: Resident Rights (7 deficiencies)
27 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Philadelphia, PA
Fairview Rehab And Care Center
2-star overall rating with 1-star inspections with $47,181 in total fines with 31 recent health deficiencies with 27 fire-safety deficiencies in the latest cycle
184 Bethlehem Pike, Philadelphia, PA
(215) 247-5311
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
176
Certified beds
Average residents
157
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Imperial Healthcare Group
Operator or chain grouping
Approved since
1989-03-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,929
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.82
Baseline 20.23% · Performance 20.59% · Measure score 1.82 · Achievement 1.82 · Improvement 0
Healthcare-associated infections
6.84
Baseline 5.51% · Performance 5.79% · Measure score 6.84 · Achievement 6.84 · Improvement 0
Total nurse turnover
0
Baseline 67.15% · Performance 68.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.45
Baseline 4.04 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.3% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 12.5% · Lower 95% interval 7.65% |
| Discharge to community | 38.82% |
50.57%
11.8 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 23.53% · Lower 95% interval 23.78% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.33% |
95.27%
3.1 pts better
|
Numerator 59 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 52.27% |
53.69%
1.4 pts worse
|
Numerator 23 · Denominator 44 |
| Discharge mobility score | 47.73% |
50.94%
3.2 pts worse
|
Numerator 21 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 1.16% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 0% · Lower 95% interval 2.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 71.55% |
42%
29.5 pts better
|
Numerator 83 · Denominator 116 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 28 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.05% |
25.2%
4.1 pts worse
|
Numerator 8 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
86.9%
4.7 pts better
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 98.7% · Q3 95.5% · Q4 97.2% · 4Q avg 91.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
93.5%
4 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.2%
1.9 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.7% · Q3 1.3% · Q4 0.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.7% |
6.5%
2.2 pts worse
|
11.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 4.9% · Q3 4.1% · Q4 14.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
6.5%
3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 6.2% · Q3 6.5% · Q4 14.4% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
19.9%
8.7 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 12.1% · Q3 10.3% · Q4 11.7% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.7%
1.1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 16.9% · Q3 17.0% · Q4 17.2% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
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 | 7.4% |
19.6%
12.2 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 13.6% · Q3 2.7% · Q4 4.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
18.3%
6.1 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 16.5% · Q3 15.8% · Q4 5.5% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.7% · Q3 0.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.7% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
26.4%
0.4 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 25.3% · Q3 29.7% · Q4 27.0% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.3%
0.7 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 5.5% · Q4 5.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.9% |
68.9%
25 pts worse
|
81.7%
37.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 56.5% · Q3 45.3% · Q4 37.3% · 4Q avg 43.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
9.8%
2.4 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.3% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.8% |
68.7%
17.9 pts worse
|
79.7%
28.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
23.1%
2.5 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 25.0% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-12 · Fire 2024-01-12
36 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2023-03-20 · Fire 2023-03-20
34 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-28
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 2025-01-18
F · Potential for more than minimal harm
2024-10-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-10-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-17
F · Potential for more than minimal harm
2024-10-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-10-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-10-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-17
F · Potential for more than minimal harm
2024-10-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-10-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-17
F · Potential for more than minimal harm
2024-10-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-10-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-17
E · Potential for more than minimal harm
2024-10-28
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 2025-01-18
E · Potential for more than minimal harm
2024-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-10-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-10-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-10-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-02-17
C · Minimal harm
2024-10-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-18
C · Minimal harm
2024-10-28
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-02-17
B · Minimal harm
2024-10-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-17
B · Minimal harm
2024-10-28
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-17
E · Potential for more than minimal harm
2024-01-12
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
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 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-01-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-15
C · Minimal harm
2024-01-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-15
C · Minimal harm
2024-01-12
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-15
E · Potential for more than minimal harm
2023-03-20
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-20
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 2023-04-19
E · Potential for more than minimal harm
2023-03-20
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-20
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-19
C · Minimal harm
2023-03-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-09
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Not marked corrected
E · Potential for more than minimal harm
2025-12-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-08-28
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-28
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 2025-09-25
E · Potential for more than minimal harm
2025-08-22
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-22
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 2025-09-25
D · Potential for more than minimal harm
2025-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-07-25
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 2025-08-22
D · Potential for more than minimal harm
2025-07-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-01-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-10-28
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 2024-12-11
E · Potential for more than minimal harm
2024-10-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-10-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-10-28
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 2024-12-11
E · Potential for more than minimal harm
2024-10-28
F907 · Environmental Deficiencies
Health
Provide enough space and equipment to meet each resident's needs
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-10-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
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 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
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 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
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 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-10-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-11
J · Immediate jeopardy
2024-09-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-06-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-25
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 2024-07-22
E · Potential for more than minimal harm
2024-05-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-02-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-01-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-12
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 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-12
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
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 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
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 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
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 2024-02-22
D · Potential for more than minimal harm
2024-01-12
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 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-12
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-02-22
F · Potential for more than minimal harm
2023-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-05
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 2024-01-17
D · Potential for more than minimal harm
2023-12-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-14
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 2023-10-02
D · Potential for more than minimal harm
2023-07-31
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-22
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-05-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-28
E · Potential for more than minimal harm
2023-05-17
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 2023-06-28
E · Potential for more than minimal harm
2023-03-20
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-20
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-20
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 2023-04-30
E · Potential for more than minimal harm
2023-03-20
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 2023-04-30
E · Potential for more than minimal harm
2023-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
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 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
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 2023-04-30
D · Potential for more than minimal harm
2023-03-20
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 2023-04-30
D · Potential for more than minimal harm
2023-03-20
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 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-20
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 2023-04-30
D · Potential for more than minimal harm
2023-03-20
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-04-30
Penalties and ownership
What sits behind the stars
$37,431
2024-09-18
Fine
Fine · fine $37,431
Fine
$9,750
2023-03-20
Fine
Fine · fine $9,750
Fine
Ownership
Main Pa Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ch Lightning Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Chrh Equities LLC
5% Or Greater Indirect Ownership Interest · Organization
Cobette, Charmaine
W-2 Managing Employee · Individual
Ens Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Gottesman, Daniel
5% Or Greater Indirect Ownership Interest · Individual
Grimaldi, Kelly
W-2 Managing Employee · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Herzka, Yisroel
Corporate Officer · Individual
Kopelowitz, Shaul
5% Or Greater Indirect Ownership Interest · Individual
The Ens Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ymcs Equities LLC
5% Or Greater Indirect Ownership Interest · Organization
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