Peoria Heights, IL

Goldwater Care Peoria Heights

1-star overall rating with 1-star inspections with $181,422 in total fines with 9 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle

5533 North Galena Road, Peoria Heights, IL

(309) 682-5428

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 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

Goldwater Care

Operator or chain grouping

Approved since

1972-02-02

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

11 facilities

Chain averages 2 overall / 2 health / 1 staffing / 3 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

0.32

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

1.04

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.03

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

3.39

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.37

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.11

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.24

CMS adjusted RN staffing hours

Adjusted total hours

2.50

CMS adjusted total nurse staffing hours

Case-mix index

1.85

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 46% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.82%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 6.31%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 6 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	5.56%	8.2% 2.6 pts worse	Numerator 3 · Denominator 54
Staff flu vaccination coverage	9.86%	42% 32.1 pts worse	Numerator 7 · Denominator 71
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.8%	89.6% 5.2 pts better	93.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 97.5% · Q4 85.7% · 4Q avg 94.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.5%	91.6% 5.9 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	2.0%	3.3% 1.3 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 2.5% · Q4 2.4% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	80.8%	50.3% 30.5 pts worse	11.4% 69.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 82.4% · Q3 91.2% · Q4 82.4% · 4Q avg 80.8%
Percentage of long-stay residents who lose too much weight	11.9%	6.5% 5.4 pts worse	5.4% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 19.4% · Q3 8.8% · Q4 10.3% · 4Q avg 11.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.3%	18.5% 2.2 pts better	19.6% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.9% · Q3 14.3% · Q4 23.1% · 4Q avg 16.3%
Percentage of long-stay residents who received an antipsychotic medication	28.3%	22.8% 5.5 pts worse	16.7% 11.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 24.0% · Q3 28.0% · Q4 27.6% · 4Q avg 28.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 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	34.5%	17.2% 17.3 pts worse	16.3% 18.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 34.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.0%	15.0% 9 pts worse	14.9% 9.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 48.3% · Q2 28.6% · Q3 13.3% · Q4 8.8% · 4Q avg 24.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.1% 1.1 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	1.3%	1.7% 0.4 pts better	1.7% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	37.9%	21.3% 16.6 pts worse	19.8% 18.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 42.8% · Q2 28.1% · Q3 43.9% · Q4 36.9% · 4Q avg 37.9%
Percentage of long-stay residents with pressure ulcers	4.2%	5.2% 1 pts better	5.1% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.5% · Q3 3.8% · Q4 2.2% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	80.5%	68.8% 11.7 pts better	81.7% 1.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 94.4% · Q3 86.5% · Q4 63.2% · 4Q avg 80.5%
Percentage of short-stay residents who newly received an antipsychotic medication	3.0%	2.3% 0.7 pts worse	1.6% 1.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 4.2% · 4Q avg 3.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	40.5%	63.0% 22.5 pts worse	79.7% 39.2 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 40.5%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-01 · Fire 2024-10-01

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2023-07-24 · Fire 2023-07-24

40 health deficiencies

Top issue: Quality of Life and Care (12 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2022-08-12 · Fire 2022-08-12

36 health deficiencies

Top issue: Quality of Life and Care (12 deficiencies)

13 fire-safety deficiencies

Top issue: Miscellaneous (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-01

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-10-30

F · Potential for more than minimal harm 2024-10-01

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-10-25

F · Potential for more than minimal harm 2024-10-01

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-11-08

F · Potential for more than minimal harm 2024-10-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-10-25

F · Potential for more than minimal harm 2024-10-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-01-03

E · Potential for more than minimal harm 2024-10-01

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2025-04-01

E · Potential for more than minimal harm 2024-10-01

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-10-01

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 2024-10-30

E · Potential for more than minimal harm 2024-10-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-01-30

E · Potential for more than minimal harm 2024-10-01

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-10-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-19

E · Potential for more than minimal harm 2024-10-01

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-10-01

K913 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure operating rooms are properly protected and written records are maintained and available for inspection.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-10-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-10-25

F · Potential for more than minimal harm 2023-07-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

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 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-07-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-08-17

F · Potential for more than minimal harm 2022-08-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-09-16

F · Potential for more than minimal harm 2022-08-12

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-09-16

F · Potential for more than minimal harm 2022-08-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-09-16

F · Potential for more than minimal harm 2022-08-12

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 2022-09-16

F · Potential for more than minimal harm 2022-08-12

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2022-09-16

F · Potential for more than minimal harm 2022-08-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-09-16

E · Potential for more than minimal harm 2022-08-12

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2022-09-16

E · Potential for more than minimal harm 2022-08-12

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-09-16

E · Potential for more than minimal harm 2022-08-12

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2022-09-16

E · Potential for more than minimal harm 2022-08-12

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 2022-09-16

E · Potential for more than minimal harm 2022-08-12

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-09-16

E · Potential for more than minimal harm 2022-08-12

K913 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure operating rooms are properly protected and written records are maintained and available for inspection.

Corrected 2022-09-16

E · Potential for more than minimal harm 2022-08-12

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-09-16

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-07

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-12-07

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-12-08

F · Potential for more than minimal harm 2025-08-06

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-08-07

D · Potential for more than minimal harm 2025-08-06

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-08-07

E · Potential for more than minimal harm 2024-12-07

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 2024-12-13

F · Potential for more than minimal harm 2024-10-01

F868 · Administration Deficiencies

Health

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

Corrected 2024-10-25

F · Potential for more than minimal harm 2024-10-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-25

F · Potential for more than minimal harm 2024-10-01

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-10-01

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 2024-10-25

D · Potential for more than minimal harm 2024-10-01

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-10-25

D · Potential for more than minimal harm 2024-07-11

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 2024-07-27

E · Potential for more than minimal harm 2024-05-18

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-08

D · Potential for more than minimal harm 2024-05-18

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 2024-06-08

D · Potential for more than minimal harm 2024-05-18

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-08

D · Potential for more than minimal harm 2024-05-18

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 2024-06-08

D · Potential for more than minimal harm 2024-05-18

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2024-06-08

E · Potential for more than minimal harm 2024-04-24

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-05-10

G · Actual harm 2024-03-21

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-10

F · Potential for more than minimal harm 2024-03-21

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-04-11

F · Potential for more than minimal harm 2024-03-21

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 2024-04-10

E · Potential for more than minimal harm 2024-03-21

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-04-10

J · Immediate jeopardy 2024-02-27

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-05-03

G · Actual harm 2024-02-27

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 2024-04-12

F · Potential for more than minimal harm 2024-02-27

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 2024-04-12

E · Potential for more than minimal harm 2024-02-27

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 2024-04-12

D · Potential for more than minimal harm 2024-02-27

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-04-12

D · Potential for more than minimal harm 2024-01-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-01-19

D · Potential for more than minimal harm 2024-01-06

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-01-19

J · Immediate jeopardy 2023-12-21

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-13

J · Immediate jeopardy 2023-12-21

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 2024-02-22

F · Potential for more than minimal harm 2023-12-21

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-02-13

F · Potential for more than minimal harm 2023-12-21

F835 · Administration Deficiencies

Health

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

Corrected 2024-02-13

D · Potential for more than minimal harm 2023-12-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-02-13

D · Potential for more than minimal harm 2023-12-21

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 2024-02-13

D · Potential for more than minimal harm 2023-12-21

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 2024-02-13

F · Potential for more than minimal harm 2023-11-30

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-12-17

F · Potential for more than minimal harm 2023-11-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-17

E · Potential for more than minimal harm 2023-11-30

F761 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-12-17

D · Potential for more than minimal harm 2023-11-30

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-12-17

F · Potential for more than minimal harm 2023-10-31

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 2023-11-22

F · Potential for more than minimal harm 2023-10-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-22

D · Potential for more than minimal harm 2023-10-31

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 2023-11-22

D · Potential for more than minimal harm 2023-10-31

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 2023-11-22

F · Potential for more than minimal harm 2023-07-24

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

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 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F835 · Administration Deficiencies

Health

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

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F837 · Administration Deficiencies

Health

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F867 · Administration Deficiencies

Health

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

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F868 · Administration Deficiencies

Health

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

Corrected 2023-08-30

F · Potential for more than minimal harm 2023-07-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-30

E · Potential for more than minimal harm 2023-07-24

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 2023-09-14

E · Potential for more than minimal harm 2023-07-24

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 2023-09-14

E · Potential for more than minimal harm 2023-07-24