Cycle 1
Health 2024-07-11 · Fire 2024-07-11
20 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Dublin, OH
Grand The
2-star overall rating with 1-star inspections with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4500 John Shield Pkwy, Dublin, OH
(614) 889-8585
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Optalis Health & Rehabilitation
Operator or chain grouping
Approved since
2015-11-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 3 staffing / 5 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
0.73
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,007
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.50% · Performance 23.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.14% · Performance 8.61% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.20
Baseline 66.04% · Performance 42.55% · Measure score 5.20 · Achievement 5.17 · Improvement 5.20
Adjusted total nurse staffing
0.53
Baseline 3.70 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 8.65% · Lower 95% interval 7.07% |
| Discharge to community | 51.38% |
50.57%
0.8 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 47.29% · Lower 95% interval 45.05% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.74% |
95.27%
2.5 pts better
|
Numerator 130 · Denominator 133 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 133 |
| Discharge self-care score | 65.79% |
53.69%
12.1 pts better
|
Numerator 50 · Denominator 76 |
| Discharge mobility score | 68.42% |
50.94%
17.5 pts better
|
Numerator 52 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 133 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.6% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 9.65% · Lower 95% interval 5.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 173 |
| Staff flu vaccination coverage | 2.16% |
42%
39.8 pts worse
|
Numerator 4 · Denominator 185 |
| Discharge function score | 77.63% |
56.45%
21.2 pts better
|
Numerator 59 · Denominator 76 |
| Transfer of health information to provider | 98.95% |
95.95%
3 pts better
|
Numerator 94 · Denominator 95 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 47.06% |
25.2%
21.9 pts better
|
Numerator 32 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 2.0 · Expected 3.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.8
1.8 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
92.4%
3.6 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.3% · Q3 94.0% · Q4 94.5% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.1% |
94.5%
2.4 pts worse
|
95.5%
3.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.9% · Q3 0.0% · Q4 2.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.1% |
26.1%
11 pts better
|
11.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 20.3% · Q3 14.3% · Q4 7.1% · 4Q avg 15.1% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
6.2%
3.3 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 0.0% · Q3 0.0% · Q4 4.1% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
25.4%
1.8 pts better
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 25.0% · Q3 20.8% · Q4 20.3% · 4Q avg 23.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
11.5%
2.7 pts worse
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 16.1% · Q3 14.8% · Q4 9.7% · 4Q avg 14.2% · 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 | 10.3% |
7.7%
2.6 pts worse
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 8.4% · Q3 4.9% · Q4 7.8% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
6.2%
0.2 pts worse
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 10.4% · Q3 5.8% · Q4 2.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.2%
0.3 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 27.2% |
21.7%
5.5 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 21.2% · Q3 29.2% · Q4 25.9% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
3.7%
1.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.0% · Q3 7.1% · Q4 6.8% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
78.1%
20.8 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.6% · Q3 98.8% · Q4 98.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
12.5%
6 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
75.6%
22.3 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.9% |
25.1%
11.8 pts worse
|
23.9%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.9% · Observed 41.0% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-09 · Fire 2023-01-09
31 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-17 · Fire 2021-05-17
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-29
F · Potential for more than minimal harm
2024-07-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-29
F · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-29
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-07-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-29
F · Potential for more than minimal harm
2023-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-07
E · Potential for more than minimal harm
2021-05-17
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 2021-06-11
E · Potential for more than minimal harm
2021-05-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-06-11
E · Potential for more than minimal harm
2021-05-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-11
E · Potential for more than minimal harm
2021-05-17
K524 · Services Deficiencies
Fire Safety
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2021-06-11
C · Minimal harm
2021-05-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
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 2026-01-02
D · Potential for more than minimal harm
2025-12-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-03-03
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 2025-03-07
D · Potential for more than minimal harm
2025-03-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-07
F · Potential for more than minimal harm
2024-07-11
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 2024-07-29
F · Potential for more than minimal harm
2024-07-11
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 2024-07-29
E · Potential for more than minimal harm
2024-07-11
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 2024-07-29
D · Potential for more than minimal harm
2024-07-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-07-11
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 2024-07-29
D · Potential for more than minimal harm
2024-07-11
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 2024-07-29
D · Potential for more than minimal harm
2024-07-11
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-07-11
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 2024-07-29
D · Potential for more than minimal harm
2024-07-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-07-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-29
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 2024-07-29
D · Potential for more than minimal harm
2024-07-11
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 2024-07-29
D · Potential for more than minimal harm
2024-07-11
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-07-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-29
B · Minimal harm
2024-07-11
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 2024-07-25
F · Potential for more than minimal harm
2023-09-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-09-02
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 2023-09-14
D · Potential for more than minimal harm
2023-03-30
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 2023-04-21
G · Actual harm
2023-01-09
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 2023-02-07
G · Actual harm
2023-01-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
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 2023-02-07
F · Potential for more than minimal harm
2023-01-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
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 2023-02-07
F · Potential for more than minimal harm
2023-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
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 2023-02-07
E · Potential for more than minimal harm
2023-01-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-02-07
E · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-09
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-09
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 2023-02-07
D · Potential for more than minimal harm
2023-01-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-02-07
D · Potential for more than minimal harm
2021-05-17
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 2021-06-11
D · Potential for more than minimal harm
2021-05-17
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 2021-06-11
D · Potential for more than minimal harm
2021-05-17
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 2021-06-11
Penalties and ownership
What sits behind the stars
Ownership
Om Holdco 4 LLC
5% Or Greater Direct Ownership Interest · Organization
Batdorff, Danielle
Operational/Managerial Control · Individual
Charles A. Dunn Agreement Of Trust 3.14.2001
5% Or Greater Indirect Ownership Interest · Organization
Charles Franklin LLC
5% Or Greater Indirect Ownership Interest · Organization
East West Bank
5% Or Greater Security Interest · Organization
East West Bank
5% Or Greater Mortgage Interest · Organization
Hemant Shah 2018 Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Katula, Douglas
Operational/Managerial Control · Individual
Om Note Holdco 4 LLC
5% Or Greater Indirect Ownership Interest · Organization
Optum Management Solutions. Inc
Operational/Managerial Control · Organization
Paar 108 LLC
5% Or Greater Indirect Ownership Interest · Organization
Patel, Rajan
Operational/Managerial Control · Individual
Pinal R. Patel 2017 Irrevocable Trust F/B/O Aarna R. Patel
5% Or Greater Indirect Ownership Interest · Organization
Pinal R. Patel 2017 Irrevocable Trust F/B/O Ansh R. Patel
5% Or Greater Indirect Ownership Interest · Organization
Pinal R. Patel 2020 Irrevocable Family Trust Uad 10-6-2020
5% Or Greater Indirect Ownership Interest · Organization
Rajan G Patel 2020 Irr Fam Tr Uad 12-3-2020
5% Or Greater Indirect Ownership Interest · Organization
Sharon, Robert
Operational/Managerial Control · Individual
Snw LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
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