Oakwood Village, OH

Grande Oaks

2-star overall rating with 1-star inspections with $17,020 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

24579 Broadway Ave, Oakwood Village, OH

(440) 439-7976

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Embassy Healthcare

Operator or chain grouping

Approved since

1991-02-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

37 facilities

Chain averages 3 overall / 2 health / 2 staffing / 5 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

0.24

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.65

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.19

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.08

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.88

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.61

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.12

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.18

CMS adjusted RN staffing hours

Adjusted total hours

3.17

CMS adjusted total nurse staffing hours

Case-mix index

1.76

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,081

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

Performance score

27.87

Composite VBP score used to determine payment impact.

Payment multiplier

0.9847

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

1.09

Performance 59.21% · Measure score 1.09 · Achievement 1.09 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

4.48

Baseline 1.23 hours · Performance 3.50 hours · Measure score 4.48 · Achievement 1.47 · Improvement 4.48

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 7 · 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 Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 131
Staff flu vaccination coverage	11.3%	42% 30.7 pts worse	Numerator 13 · Denominator 115
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 3 · 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 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · 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	48.0%	92.4% 44.4 pts worse	93.4% 45.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 50.0% · Q3 50.0% · Q4 47.6% · 4Q avg 48.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	86.5%	94.5% 8 pts worse	95.5% 9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 86.5%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.3% 3.3 pts better	3.3% 3.3 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 who have depressive symptoms	0.7%	26.1% 25.4 pts better	11.4% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight	4.3%	6.2% 1.9 pts better	5.4% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.3% · Q3 5.0% · Q4 0.0% · 4Q avg 4.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.3%	25.4% 4.1 pts better	19.6% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 26.1% · Q3 22.5% · Q4 15.0% · 4Q avg 21.3%
Percentage of long-stay residents who received an antipsychotic medication	8.2%	11.5% 3.3 pts better	16.7% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.7% · Q3 8.7% · Q4 4.0% · 4Q avg 8.2% · 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	0.0%	7.7% 7.7 pts better	16.3% 16.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	0.8%	6.2% 5.4 pts better	14.9% 14.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.2% 0.2 pts worse	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · 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	24.1%	21.7% 2.4 pts worse	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 27.5% · Q3 22.8% · Q4 14.3% · 4Q avg 24.1%
Percentage of long-stay residents with pressure ulcers	10.1%	3.7% 6.4 pts worse	5.1% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 10.8% · Q3 7.9% · Q4 9.8% · 4Q avg 10.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	10.3%	78.1% 67.8 pts worse	81.7% 71.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.5% · Q3 16.0% · Q4 10.5% · 4Q avg 10.3%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	22.7%	75.6% 52.9 pts worse	79.7% 57 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 22.7%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-27 · Fire 2025-03-27

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2022-09-09 · Fire 2022-09-09

52 health deficiencies

Top issue: Quality of Life and Care (13 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-08-22 · Fire 2019-08-22

10 health deficiencies

Top issue: Nursing and Physician Services (3 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-15

F · Potential for more than minimal harm 2025-03-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-15

F · Potential for more than minimal harm 2025-03-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-04-15

F · Potential for more than minimal harm 2025-03-27

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-04-15

F · Potential for more than minimal harm 2025-03-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-04-15

E · Potential for more than minimal harm 2025-03-27

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2025-04-15

F · Potential for more than minimal harm 2022-09-09

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-09-09

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-09-09

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-09-09

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2022-11-23

F · Potential for more than minimal harm 2019-08-22

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2019-11-12

F · Potential for more than minimal harm 2019-08-22

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2019-10-22

F · Potential for more than minimal harm 2019-08-22

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-10-22

F · Potential for more than minimal harm 2019-08-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-10-22

F · Potential for more than minimal harm 2019-08-22

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2019-10-22

F · Potential for more than minimal harm 2019-08-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-11-12

F · Potential for more than minimal harm 2019-08-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2019-11-12

F · Potential for more than minimal harm 2019-08-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2019-10-22

F · Potential for more than minimal harm 2019-08-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2019-10-22

E · Potential for more than minimal harm 2019-08-22

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2019-10-22

E · Potential for more than minimal harm 2019-08-22

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 2019-10-22

E · Potential for more than minimal harm 2019-08-22

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2019-10-22

E · Potential for more than minimal harm 2019-08-22

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2019-11-12

C · Minimal harm 2019-08-22

E33 · Emergency Preparedness Deficiencies

Fire Safety

Establish methods for sharing information.

Corrected 2019-11-12

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-10-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-31

E · Potential for more than minimal harm 2025-10-28

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 2025-10-31

D · Potential for more than minimal harm 2025-10-28

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-10-28

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-10-28

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-10-28

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-10-28

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-03-27

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 2025-04-15

D · Potential for more than minimal harm 2025-03-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-15

G · Actual harm 2024-12-02

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-18

F · Potential for more than minimal harm 2024-12-02

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 2025-01-03

F · Potential for more than minimal harm 2024-12-02

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-01-03

F · Potential for more than minimal harm 2024-12-02

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 2025-01-03

F · Potential for more than minimal harm 2024-12-02

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 2025-01-03

F · Potential for more than minimal harm 2024-12-02

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2025-01-03

F · Potential for more than minimal harm 2024-12-02

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2025-01-03

F · Potential for more than minimal harm 2024-12-02

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 2025-01-03

D · Potential for more than minimal harm 2024-12-02

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 2025-01-03

D · Potential for more than minimal harm 2024-12-02

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2025-01-03

D · Potential for more than minimal harm 2024-12-02

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 2025-01-03

D · Potential for more than minimal harm 2024-12-02

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-01-03

D · Potential for more than minimal harm 2024-12-02

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2025-01-03

D · Potential for more than minimal harm 2024-12-02

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-01-03

D · Potential for more than minimal harm 2024-12-02

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-01-03

D · Potential for more than minimal harm 2024-12-02

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2025-01-03

D · Potential for more than minimal harm 2024-09-18

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 2024-10-08

D · Potential for more than minimal harm 2024-09-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-10-08

D · Potential for more than minimal harm 2024-09-18

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-10-08

D · Potential for more than minimal harm 2024-09-18

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-10-08

D · Potential for more than minimal harm 2024-09-18

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 2024-10-08

D · Potential for more than minimal harm 2024-09-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-08

E · Potential for more than minimal harm 2024-09-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-08

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

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 2024-08-02

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

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 2024-08-02

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

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-02

F · Potential for more than minimal harm 2024-05-20

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-20

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-07

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

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-19

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

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 2024-04-19

D · Potential for more than minimal harm 2024-02-07

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 2024-04-19

E · Potential for more than minimal harm 2023-12-18

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-01-26

F · Potential for more than minimal harm 2023-07-06

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-07-06

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-07-17

D · Potential for more than minimal harm 2023-05-17

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 2023-07-17

D · Potential for more than minimal harm 2023-05-17

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 2023-07-17

J · Immediate jeopardy 2022-09-09

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-23

G · Actual harm 2022-09-09

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

F868 · Administration Deficiencies

Health

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

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-09-09

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 2022-11-23

E · Potential for more than minimal harm 2022-09-09

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 2022-11-23

E · Potential for more than minimal harm 2022-09-09

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-09-09

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 2022-11-23

E · Potential for more than minimal harm 2022-09-09

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 2022-11-23