Cycle 1
Health 2023-12-26 · Fire 2023-12-26
44 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
25 fire-safety deficiencies
Top issue: Miscellaneous (7 deficiencies)
Cincinnati, OH
Harmony Court Rehab And Nursing
2-star overall rating with 1-star inspections with abuse icon flag with $100,887 in total fines with 44 recent health deficiencies with 25 fire-safety deficiencies in the latest cycle
6969 Glenmeadow Lane, Cincinnati, OH
(513) 351-7007
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
120
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.39
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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
0
Baseline 56.04% · Performance 63.93% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.57 hours · Performance 3.18 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · 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 15 · 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 | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 1 · Denominator 27 · Adjusted rate 2.81% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.68% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 146 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 139 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · 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 12 · 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 | 91.2% |
92.4%
1.2 pts worse
|
93.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 94.2% · Q3 92.3% · Q4 88.8% · 4Q avg 91.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.8% |
94.5%
3.7 pts worse
|
95.5%
4.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.9% · Q3 3.8% · Q4 2.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 95.8% |
26.1%
69.7 pts worse
|
11.4%
84.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 96.7% · Q3 95.9% · Q4 96.0% · 4Q avg 95.8% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.2%
1.5 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 3.3% · Q3 3.4% · Q4 3.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.6% |
25.4%
0.2 pts worse
|
19.6%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 22.8% · Q3 25.3% · Q4 28.0% · 4Q avg 25.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
11.5%
0.5 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.1% · Q3 14.8% · Q4 15.7% · 4Q avg 11.0% · 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 | 0.9% |
7.7%
6.8 pts better
|
16.3%
15.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.1% |
6.2%
5.1 pts better
|
14.9%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.5%
0.3 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.4% |
21.7%
13.3 pts better
|
19.8%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 5.5% · Q3 1.7% · Q4 4.3% · 4Q avg 8.4% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
3.7%
3.9 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.4% · Q3 10.1% · Q4 6.6% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.6% |
78.1%
16.5 pts worse
|
81.7%
20.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 62.5% · Q3 77.8% · Q4 68.3% · 4Q avg 61.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.2% |
75.6%
30.4 pts worse
|
79.7%
34.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-27 · Fire 2020-02-27
16 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2018-12-19 · Fire 2018-12-19
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
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 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
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 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-05
F · Potential for more than minimal harm
2023-09-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-25
F · Potential for more than minimal harm
2020-02-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-04-22
F · Potential for more than minimal harm
2020-02-27
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2020-04-22
F · Potential for more than minimal harm
2020-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-22
F · Potential for more than minimal harm
2020-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-04-22
F · Potential for more than minimal harm
2020-02-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-04-22
F · Potential for more than minimal harm
2020-02-27
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 2020-04-22
E · Potential for more than minimal harm
2020-02-27
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 2020-04-22
E · Potential for more than minimal harm
2020-02-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-04-22
E · Potential for more than minimal harm
2020-02-27
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2020-04-22
E · Potential for more than minimal harm
2020-02-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-04-22
F · Potential for more than minimal harm
2018-12-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-01-18
F · Potential for more than minimal harm
2018-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-18
F · Potential for more than minimal harm
2018-12-19
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-01-18
F · Potential for more than minimal harm
2018-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
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 2019-01-18
E · Potential for more than minimal harm
2018-12-19
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
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 2019-01-18
E · Potential for more than minimal harm
2018-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
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 2019-01-18
E · Potential for more than minimal harm
2018-12-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-01-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-30
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 2025-11-21
D · Potential for more than minimal harm
2025-10-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-30
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 2025-11-21
D · Potential for more than minimal harm
2025-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-05-14
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 2025-06-06
D · Potential for more than minimal harm
2025-05-14
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 2025-06-06
D · Potential for more than minimal harm
2024-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-10-30
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 2024-11-22
D · Potential for more than minimal harm
2024-10-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-02-07
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 2024-02-08
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 2024-02-08
J · Immediate jeopardy
2023-12-26
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 2024-02-08
F · Potential for more than minimal harm
2023-12-26
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 2024-02-08
F · Potential for more than minimal harm
2023-12-26
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 2024-02-08
F · Potential for more than minimal harm
2023-12-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-12-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
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 2024-02-08
E · Potential for more than minimal harm
2023-12-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-08
E · Potential for more than minimal harm
2023-12-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
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 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-12-26
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-08
C · Minimal harm
2023-12-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-11
E · Potential for more than minimal harm
2020-02-27
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 2020-04-22
E · Potential for more than minimal harm
2020-02-27
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 2020-04-22
E · Potential for more than minimal harm
2020-02-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-04-22
E · Potential for more than minimal harm
2020-02-27
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 2020-04-22
E · Potential for more than minimal harm
2020-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-22
E · Potential for more than minimal harm
2020-02-27
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 2020-04-22
D · Potential for more than minimal harm
2020-02-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-04-22
D · Potential for more than minimal harm
2020-02-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-04-22
D · Potential for more than minimal harm
2020-02-27
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 2020-04-22
D · Potential for more than minimal harm
2020-02-27
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2020-04-22
D · Potential for more than minimal harm
2020-02-27
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 2020-04-22
D · Potential for more than minimal harm
2020-02-27
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 2020-04-22
D · Potential for more than minimal harm
2020-02-27
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 2020-04-22
F · Potential for more than minimal harm
2018-12-19
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 2019-01-18
F · Potential for more than minimal harm
2018-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-18
F · Potential for more than minimal harm
2018-12-19
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 2019-01-18
E · Potential for more than minimal harm
2018-12-19
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 2019-01-18
E · Potential for more than minimal harm
2018-12-19
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 2019-01-18
E · Potential for more than minimal harm
2018-12-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-01-18
E · Potential for more than minimal harm
2018-12-19
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
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 2019-01-18
D · Potential for more than minimal harm
2018-12-19
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 2019-01-18
D · Potential for more than minimal harm
2018-12-19
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 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
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 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-01-18
D · Potential for more than minimal harm
2018-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-01-18
Penalties and ownership
What sits behind the stars
$100,887
2023-11-08
Fine
Fine · fine $100,887
Fine
$0
2023-11-08
Payment Denial
Payment Denial · denial start 2024-01-23 · 16 days
16 day denial
Ownership
Hcwe Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Brecher, Mendel
5% Or Greater Indirect Ownership Interest · Individual
Brecher, Libby
5% Or Greater Indirect Ownership Interest · Individual
Lichtman, Chana
5% Or Greater Indirect Ownership Interest · Individual
Lichtman, Sara
5% Or Greater Indirect Ownership Interest · Individual
Zimmerman, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Brecher, Mendel
Corporate Officer · Individual
Combs, Linda
W-2 Managing Employee · Individual
King, Crystal
W-2 Managing Employee · Individual
S & T Bank
5% Or Greater Security Interest · Organization
Nearby options
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2-star overall rating with 1-star inspections with 13 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
#3
Wellspring Health Center
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2-star overall rating with 2-star inspections with $122,030 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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