Cycle 1
Health 2024-04-03 · Fire 2024-04-03
26 health deficiencies
Top issue: Resident Rights (7 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Baltimore, MD
Fayette Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $162,159 in total fines with 26 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1217 West Fayette Street, Baltimore, MD
(410) 727-3947
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
156
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Communicare Health
Operator or chain grouping
Approved since
1989-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
122 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
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
1.97
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,401
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.33
Baseline 17.62% · Performance 20.82% · Measure score 1.33 · Achievement 1.33 · Improvement 0
Healthcare-associated infections
2.17
Baseline 5.93% · Performance 7.18% · Measure score 2.17 · Achievement 2.17 · Improvement 0
Total nurse turnover
6.75
Baseline 47.87% · Performance 36.11% · Measure score 6.75 · Achievement 6.75 · Improvement 4.61
Adjusted total nurse staffing
0.51
Baseline 3.31 hours · Performance 3.22 hours · Measure score 0.51 · Achievement 0.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.94% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 20% · Lower 95% interval 8.67% |
| Discharge to community | 54.93% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 45.9% · Lower 95% interval 41.76% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 53 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 21 · Denominator 35 |
| Discharge mobility score | 54.29% |
50.94%
3.4 pts better
|
Numerator 19 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 0.65% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 153 |
| Staff flu vaccination coverage | 56.4% |
42%
14.4 pts better
|
Numerator 97 · Denominator 172 |
| Discharge function score | 62.86% |
56.45%
6.4 pts better
|
Numerator 22 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.63% |
96.28%
5.7 pts worse
|
Numerator 29 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 10 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.9%
7.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.3%
0.4 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.7% · Q3 2.7% · Q4 2.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 43.9% |
21.4%
22.5 pts worse
|
11.4%
32.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 47.5% · Q3 60.6% · Q4 46.2% · 4Q avg 43.9% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.7%
0.3 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.6% · Q3 9.2% · Q4 4.5% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.2% |
16.1%
11.1 pts worse
|
19.6%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 26.2% · Q3 28.4% · Q4 28.3% · 4Q avg 27.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
15.3%
2.7 pts worse
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 22.8% · Q3 17.9% · Q4 12.5% · 4Q avg 18.0% · 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 | 14.4% |
26.6%
12.2 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 22.8% · Q3 5.2% · Q4 8.6% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.8% |
22.9%
4.9 pts worse
|
14.9%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 34.7% · Q3 21.6% · Q4 30.5% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.5%
1.3 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
25.4%
2.8 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 26.4% · Q3 22.3% · Q4 20.9% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.3%
1.9 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.5% · Q3 5.5% · Q4 5.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
78.4%
1.8 pts better
|
81.7%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 82.9% · Q3 75.0% · Q4 70.5% · 4Q avg 80.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
9.9%
0.2 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 11.4% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.7% · Q3 3.0% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
80.6%
1 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
21.2%
9 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 27.3% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-03-11 · Fire 2019-03-11
22 health deficiencies
Top issue: Resident Rights (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2017-10-06 · Fire 2017-10-06
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-03
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-03
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 2024-05-22
F · Potential for more than minimal harm
2024-04-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-03
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 2024-05-22
F · Potential for more than minimal harm
2024-04-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-03
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 2024-05-22
D · Potential for more than minimal harm
2024-04-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-03
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-05-22
E · Potential for more than minimal harm
2019-03-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-26
E · Potential for more than minimal harm
2024-04-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-04-03
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 2024-06-12
E · Potential for more than minimal harm
2024-04-03
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 2024-06-12
E · Potential for more than minimal harm
2024-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-04-03
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 2024-06-12
E · Potential for more than minimal harm
2024-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-04-03
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 2024-06-12
E · Potential for more than minimal harm
2024-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-03
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 2024-06-12
J · Immediate jeopardy
2023-10-02
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 2023-11-16
G · Actual harm
2023-10-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-17
D · Potential for more than minimal harm
2023-10-02
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 2023-11-16
D · Potential for more than minimal harm
2023-10-02
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-02
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 2023-11-16
D · Potential for more than minimal harm
2023-10-02
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-11-16
E · Potential for more than minimal harm
2019-03-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-03-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-03-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-03-11
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-03-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-03-11
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 2019-05-08
E · Potential for more than minimal harm
2019-03-11
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 2019-05-08
D · Potential for more than minimal harm
2019-03-11
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 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
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 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
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 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-05-08
C · Minimal harm
2019-03-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-05-08
H · Actual harm
2017-10-06
F333 · Pharmacy Service Deficiencies
Health
Ensure that residents are safe from serious medication errors.
Corrected 2017-09-10
G · Actual harm
2017-10-06
F155 · Resident Rights Deficiencies
Health
Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-10-06
F226 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Corrected 2017-11-19
D · Potential for more than minimal harm
2017-10-06
F241 · Resident Rights Deficiencies
Health
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Corrected 2017-11-19
D · Potential for more than minimal harm
2017-10-06
F272 · Resident Assessment and Care Planning Deficiencies
Health
Conduct initial and periodic assessments of each resident's functional capacity.
Corrected 2017-11-19
D · Potential for more than minimal harm
2017-10-06
F279 · Resident Assessment and Care Planning Deficiencies
Health
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2017-11-19
D · Potential for more than minimal harm
2017-10-06
F280 · Resident Assessment and Care Planning Deficiencies
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-11-19
D · Potential for more than minimal harm
2017-10-06
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-11-19
D · Potential for more than minimal harm
2017-10-06
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2017-11-19
Penalties and ownership
What sits behind the stars
$0
2024-04-03
Payment Denial
Payment Denial · denial start 2024-05-17 · 26 days
26 day denial
$162,159
2023-10-02
Fine
Fine · fine $162,159
Fine
Ownership
Second Option Op Co LLC
5% Or Greater Direct Ownership Interest · Organization
Bharaj, Narender
Operational/Managerial Control · Individual
Burnette, Tiffany
Operational/Managerial Control · Individual
C R Stoltz Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
C.r. Stoltz Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Falling Mgt Co LLC
Operational/Managerial Control · Organization
Groves, Donna
Operational/Managerial Control · Individual
Hc Real Estate Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
I. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Omg Re Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Option Holdings Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
R.s. Wilheim Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Romeo, Dominic
Operational/Managerial Control · Individual
Romeo, Dominic
Corporate Officer · Individual
Ronald S Wilheim 2012 Spousal Trust
5% Or Greater Indirect Ownership Interest · Organization
Rosedale Family Investment Company, Inc
5% Or Greater Indirect Ownership Interest · Organization
Rrw, LLC
5% Or Greater Indirect Ownership Interest · Organization
S.l. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Stoltz, Charles
Corporate Officer · Individual
Wilheim Family Investment Company, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Wilheim, Ronald
Corporate Officer · Individual
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