Cycle 1
Health 2024-12-20 · Fire 2024-12-20
17 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
21 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Detroit, MI
Heritage Manor Nursing and Rehabilitation Center
2-star overall rating with 2-star inspections with abuse icon flag with 17 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
9500 Grand River Ave, Detroit, MI
(313) 491-7920
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pioneer Healthcare Management
Operator or chain grouping
Approved since
1974-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.27
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,782
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.29% · Performance 22.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.72
Baseline 5.85% · Performance 7.32% · Measure score 1.72 · Achievement 1.72 · Improvement 0
Total nurse turnover
0
Baseline 57.73% · Performance 64.42% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.40
Baseline 3.35 hours · Performance 4.33 hours · Measure score 4.40 · Achievement 4.40 · Improvement 3.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 196 · Observed rate 10.71% · Lower 95% interval 8.53% |
| Discharge to community | 31.03% |
50.57%
19.5 pts worse
|
Worse than the National Rate · Eligible stays 128 · Observed rate 17.97% · Lower 95% interval 23.64% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 44 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 18 · Denominator 32 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 16 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 2.62% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 7.59% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 75 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 172 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 20 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.33% |
25.2%
16.9 pts worse
|
Numerator 2 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 39.7% |
95.0%
55.3 pts worse
|
93.4%
53.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.8% · Q2 36.7% · Q3 36.7% · Q4 29.0% · 4Q avg 39.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.8% |
95.0%
18.2 pts worse
|
95.5%
18.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.1%
0.6 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.3% · Q3 2.2% · Q4 2.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 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 who lose too much weight | 2.3% |
5.5%
3.2 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
19.6%
6.5 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.4% · Q3 9.1% · Q4 7.1% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.4% |
16.5%
12.9 pts worse
|
16.7%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 25.6% · Q3 28.8% · Q4 29.6% · 4Q avg 29.4% · 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 | 8.3% |
13.9%
5.6 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 2.8% · Q3 7.6% · Q4 11.1% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
11.7%
2.9 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 9.9% · Q3 12.6% · Q4 3.1% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 1.0% · Q4 0.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.5% |
20.4%
10.9 pts better
|
19.8%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.6% · Q3 10.3% · Q4 6.4% · 4Q avg 9.5% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.6%
1.2 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 11.2% · Q3 2.0% · Q4 3.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 8.4% |
82.8%
74.4 pts worse
|
81.7%
73.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 11.2% · Q3 1.2% · Q4 0.0% · 4Q avg 8.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
11.5%
0.8 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 15.0% · Expected 15.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 2.9% · Q3 2.9% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 17.6% |
79.5%
61.9 pts worse
|
79.7%
62.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 17.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.7% |
24.2%
10.5 pts better
|
23.9%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 17.5% · Expected 30.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-01 · Fire 2023-11-01
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
24 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2022-11-22 · Fire 2022-11-22
7 health deficiencies
Top issue: Environmental (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-20
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-12-20
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 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-04
E · Potential for more than minimal harm
2024-12-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-27
F · Potential for more than minimal harm
2023-11-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-25
F · Potential for more than minimal harm
2023-11-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-28
F · Potential for more than minimal harm
2023-11-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-25
F · Potential for more than minimal harm
2023-11-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-11-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-04
F · Potential for more than minimal harm
2023-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-21
F · Potential for more than minimal harm
2023-11-01
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-11-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-04
F · Potential for more than minimal harm
2023-11-01
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 2023-12-11
F · Potential for more than minimal harm
2023-11-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-04
F · Potential for more than minimal harm
2023-11-01
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 2023-12-06
F · Potential for more than minimal harm
2023-11-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-11-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-01
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 2023-12-04
E · Potential for more than minimal harm
2023-11-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-26
E · Potential for more than minimal harm
2023-11-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-01
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-11-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-01
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-06
F · Potential for more than minimal harm
2022-11-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-03
F · Potential for more than minimal harm
2022-11-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-04
F · Potential for more than minimal harm
2022-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-04
F · Potential for more than minimal harm
2022-11-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-04
F · Potential for more than minimal harm
2022-11-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-04
F · Potential for more than minimal harm
2022-11-22
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 2023-01-04
E · Potential for more than minimal harm
2022-11-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-11-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-04
E · Potential for more than minimal harm
2022-11-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-04
E · Potential for more than minimal harm
2022-11-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-04
E · Potential for more than minimal harm
2022-11-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-31
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-18
F · Potential for more than minimal harm
2025-06-25
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 2025-07-29
F · Potential for more than minimal harm
2025-06-25
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 2025-07-29
D · Potential for more than minimal harm
2025-05-19
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-05-28
E · Potential for more than minimal harm
2024-12-20
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 2025-01-27
E · Potential for more than minimal harm
2024-12-20
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 2025-01-27
E · Potential for more than minimal harm
2024-12-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
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 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
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 2025-01-27
D · Potential for more than minimal harm
2024-12-20
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 2025-01-27
D · Potential for more than minimal harm
2024-12-20
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 2025-01-27
D · Potential for more than minimal harm
2024-12-20
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 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-09-25
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 2024-10-14
D · Potential for more than minimal harm
2024-09-25
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 2024-10-14
D · Potential for more than minimal harm
2024-05-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-29
G · Actual harm
2024-04-24
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 2024-05-22
F · Potential for more than minimal harm
2024-04-24
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-24
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 2024-05-22
E · Potential for more than minimal harm
2024-04-24
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-24
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 2024-05-22
D · Potential for more than minimal harm
2024-03-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-27
D · Potential for more than minimal harm
2023-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-24
E · Potential for more than minimal harm
2022-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
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 2022-12-23
D · Potential for more than minimal harm
2022-11-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-11-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-22
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 2022-12-23
D · Potential for more than minimal harm
2022-11-22
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2022-12-23
Penalties and ownership
What sits behind the stars
$0
2024-04-24
Payment Denial
Payment Denial · denial start 2024-05-23 · 6 days
6 day denial
$0
2023-11-01
Payment Denial
Payment Denial · denial start 2024-02-01 · 25 days
25 day denial
Ownership
Uddin, Fahim
5% Or Greater Direct Ownership Interest · Individual
Henderson, Daryl
W-2 Managing Employee · Individual
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