Silver Spring, MD

Fox Chase Healthcare

1-star overall rating with 1-star inspections with 35 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

2015 East-West Highway, Silver Spring, MD

(301) 587-2400

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Engage Healthcare

Operator or chain grouping

Approved since

1989-09-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 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

0.48

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

0.84

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.92

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.24

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

1.32

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

2.97

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

0.38

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.15

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.57

CMS adjusted RN staffing hours

Adjusted total hours

3.87

CMS adjusted total nurse staffing hours

Case-mix index

1.14

Higher values indicate more complex resident acuity

RN turnover

70%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,375

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

Performance score

6.01

Composite VBP score used to determine payment impact.

Payment multiplier

0.9806

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.81% · Performance 21.86% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 5.97% · Performance 8.47% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0.9

Baseline 61.82% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0

Adjusted total nurse staffing

1.50

Baseline 2.9 hours · Performance 3.48 hours · Measure score 1.50 · Achievement 1.40 · Improvement 1.50

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.35%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 7.07%
Discharge to community	33.67%	50.57% 16.9 pts worse	Worse than the National Rate · Eligible stays 52 · Observed rate 21.15% · Lower 95% interval 21.37%
Medicare spending per beneficiary	1.25	1.02 0.2 pts worse
Drug regimen review with follow-up	90%	95.27% 5.3 pts worse	Numerator 36 · Denominator 40
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 40
Discharge self-care score	55.56%	53.69% 1.9 pts better	Numerator 15 · Denominator 27
Discharge mobility score	62.96%	50.94% 12 pts better	Numerator 17 · Denominator 27
Pressure ulcers or injuries, new or worsened	2.5%	2.29% 0.2 pts worse	Numerator 1 · Denominator 40 · Adjusted rate 2.11%
Healthcare-associated infections requiring hospitalization	8.47%	7.12% 1.4 pts worse	No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 4.77%
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 101 · Denominator 101
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	59.26%	56.45% 2.8 pts better	Numerator 16 · Denominator 27
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 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 26

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.8	1.3 2.5 pts worse	1.9 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.3 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.0	1.2 1.8 pts worse	1.8 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.8 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	45.4%	91.9% 46.5 pts worse	93.4% 48 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 41.3% · Q3 38.7% · Q4 55.4% · 4Q avg 45.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	44.8%	96.6% 51.8 pts worse	95.5% 50.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 44.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.6%	2.3% 0.7 pts better	3.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 1.6% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	14.7%	21.4% 6.7 pts better	11.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 27.1% · Q3 5.3% · Q4 22.4% · 4Q avg 14.7%
Percentage of long-stay residents who lose too much weight	6.3%	5.7% 0.6 pts worse	5.4% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.9% · Q3 8.5% · Q4 4.8% · 4Q avg 6.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.3%	16.1% 4.8 pts better	19.6% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.5% · Q3 14.8% · Q4 18.5% · 4Q avg 11.3%
Percentage of long-stay residents who received an antipsychotic medication	19.1%	15.3% 3.8 pts worse	16.7% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 17.2% · Q3 20.5% · Q4 25.0% · 4Q avg 19.1% · 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	8.7%	26.6% 17.9 pts better	16.3% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.9% · Q3 3.3% · Q4 17.0% · 4Q avg 8.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.5%	22.9% 10.4 pts better	14.9% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 6.9% · Q3 8.8% · Q4 20.0% · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.3%	0.7% 0.6 pts worse	1.0% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 2.9% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.1%	1.5% 0.6 pts worse	1.7% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 3.3% · Q4 3.2% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.2%	25.4% 4.2 pts better	19.8% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 15.6% · Q3 29.8% · Q4 20.7% · 4Q avg 21.2%
Percentage of long-stay residents with pressure ulcers	7.9%	6.3% 1.6 pts worse	5.1% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 8.7% · Q3 7.3% · Q4 8.4% · 4Q avg 7.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	21.5%	78.4% 56.9 pts worse	81.7% 60.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 15.4% · Q3 4.3% · Q4 39.3% · 4Q avg 21.5%
Percentage of short-stay residents who had an outpatient emergency department visit	14.2%	9.9% 4.3 pts worse	12.0% 2.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 16.3% · Expected 12.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 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	10.7%	80.6% 69.9 pts worse	79.7% 69 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 10.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.8%	21.2% 2.6 pts worse	23.9% 0.1 pts better	Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 28.6% · Expected 28.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-10 · Fire 2025-03-10

35 health deficiencies

Top issue: Quality of Life and Care (11 deficiencies)

7 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2020-01-17 · Fire 2020-01-17

19 health deficiencies

Top issue: Administration (4 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2019-01-18 · Fire 2019-01-18

20 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-10

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 2025-05-05

F · Potential for more than minimal harm 2025-03-10

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 2025-05-05

F · Potential for more than minimal harm 2025-03-10

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2025-05-05

F · Potential for more than minimal harm 2025-03-10

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-05

F · Potential for more than minimal harm 2025-03-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-05-30

F · Potential for more than minimal harm 2025-03-10

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-05-05

D · Potential for more than minimal harm 2025-03-10

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 2025-05-05

D · Potential for more than minimal harm 2020-01-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2020-01-31

D · Potential for more than minimal harm 2020-01-17

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2020-01-31

C · Minimal harm 2020-01-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-01-31

C · Minimal harm 2020-01-17

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2020-01-31

C · Minimal harm 2020-01-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2020-01-31

B · Minimal harm 2020-01-17

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2020-01-31

D · Potential for more than minimal harm 2019-01-18

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2019-03-01

C · Minimal harm 2019-01-18

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2019-03-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-19

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 2026-01-31

F · Potential for more than minimal harm 2025-03-10

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-04-04

F · Potential for more than minimal harm 2025-03-10

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-04-04

F · Potential for more than minimal harm 2025-03-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-06-17

E · Potential for more than minimal harm 2025-03-10

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-06-17

E · Potential for more than minimal harm 2025-03-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-04-04

E · Potential for more than minimal harm 2025-03-10

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 2025-04-04

E · Potential for more than minimal harm 2025-03-10

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 2025-04-04

E · Potential for more than minimal harm 2025-03-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

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 2025-06-17

D · Potential for more than minimal harm 2025-03-10

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 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

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 2025-04-04

D · Potential for more than minimal harm 2025-03-10

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 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

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 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

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 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F843 · Administration Deficiencies

Health

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2025-06-17

D · Potential for more than minimal harm 2025-03-10

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-06-17

D · Potential for more than minimal harm 2023-09-19

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-10-11

J · Immediate jeopardy 2023-03-10

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 2023-04-06

G · Actual harm 2023-03-10

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-06

F · Potential for more than minimal harm 2023-03-10

F940 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected 2023-04-06

F · Potential for more than minimal harm 2023-03-10

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 2023-04-06

F · Potential for more than minimal harm 2023-03-10

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2023-04-06

E · Potential for more than minimal harm 2023-03-10

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-07

D · Potential for more than minimal harm 2023-03-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-06-07

D · Potential for more than minimal harm 2023-03-10

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 2023-06-07

D · Potential for more than minimal harm 2023-03-10

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-07

D · Potential for more than minimal harm 2023-03-10

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2023-06-07

D · Potential for more than minimal harm 2023-03-10

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-06-07

D · Potential for more than minimal harm 2023-03-10

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 2023-06-07

D · Potential for more than minimal harm 2023-03-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-07

F · Potential for more than minimal harm 2020-01-17

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2020-03-02

F · Potential for more than minimal harm 2020-01-17

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2020-03-02

F · Potential for more than minimal harm 2020-01-17

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2020-03-02

F · Potential for more than minimal harm 2020-01-17

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2020-03-02

F · Potential for more than minimal harm 2020-01-17

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2020-03-02

E · Potential for more than minimal harm 2020-01-17

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 2020-03-02

E · Potential for more than minimal harm 2020-01-17

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2020-03-02

E · Potential for more than minimal harm 2020-01-17

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 2020-03-02

E · Potential for more than minimal harm 2020-01-17

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 2020-03-02

E · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2020-01-17

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2020-03-02

D · Potential for more than minimal harm 2020-01-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-03-02

D · Potential for more than minimal harm 2020-01-17

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 2020-03-02

D · Potential for more than minimal harm 2019-01-18

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 2019-02-22

D · Potential for more than minimal harm 2019-01-18

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2019-02-22

D · Potential for more than minimal harm 2019-01-18

F761 · Pharmacy Service Deficiencies

Health

Corrected 2019-02-22

B · Minimal harm 2019-01-18

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2019-02-22

B · Minimal harm 2019-01-18

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-02-22

B · Minimal harm 2019-01-18