Chelsea, MA

Highland Park Rehabilitation And Healthcare Center

1-star overall rating with 1-star inspections with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

255 Central Avenue, Chelsea, MA

(617) 884-5700

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

195

Certified beds

Average residents

169

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Marquis Health Services

Operator or chain grouping

Approved since

1992-09-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

81 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.56

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.49

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.12

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.17

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.05

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

2.88

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.47

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.07

CMS adjusted total nurse staffing hours

Case-mix index

1.41

Higher values indicate more complex resident acuity

RN turnover

82%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,295

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

Performance score

50.41

Composite VBP score used to determine payment impact.

Payment multiplier

1.0046

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.69

Baseline 23.56% · Performance 18.21% · Measure score 7.69 · Achievement 6.95 · Improvement 7.69

Healthcare-associated infections

4.86

Baseline 7.02% · Performance 6.38% · Measure score 4.86 · Achievement 4.86 · Improvement 2.64

Total nurse turnover

6.07

Baseline 35.71% · Performance 38.89% · Measure score 6.07 · Achievement 6.07 · Improvement 0

Adjusted total nurse staffing

1.55

Baseline 3.61 hours · Performance 3.52 hours · Measure score 1.55 · Achievement 1.55 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.83%	10.72% 1.9 pts better	No Different than the National Rate · Eligible stays 87 · Observed rate 4.6% · Lower 95% interval 5.91%
Discharge to community	43.06%	50.57% 7.5 pts worse	No Different than the National Rate · Eligible stays 62 · Observed rate 29.03% · Lower 95% interval 30.39%
Medicare spending per beneficiary	0.82	1.02 0.2 pts better
Drug regimen review with follow-up	95%	95.27% 0.3 pts worse	Numerator 57 · Denominator 60
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 60
Discharge self-care score	25%	53.69% 28.7 pts worse	Numerator 10 · Denominator 40
Discharge mobility score	22.5%	50.94% 28.4 pts worse	Numerator 9 · Denominator 40
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 60 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.38%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 3.26%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 163
Staff flu vaccination coverage	18.24%	42% 23.8 pts worse	Numerator 31 · Denominator 170
Discharge function score	25%	56.45% 31.5 pts worse	Numerator 10 · Denominator 40
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	32%	25.2% 6.8 pts better	Numerator 8 · Denominator 25

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.9 0.3 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	1.5 0.4 pts worse	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	72.6%	92.2% 19.6 pts worse	93.4% 20.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 75.0% · Q3 72.3% · Q4 67.3% · 4Q avg 72.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	48.1%	94.8% 46.7 pts worse	95.5% 47.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 48.1%
Percentage of long-stay residents experiencing one or more falls with major injury	1.0%	3.5% 2.5 pts better	3.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.6% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	75.8%	12.0% 63.8 pts worse	11.4% 64.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 72.2% · Q2 75.4% · Q3 78.7% · Q4 76.6% · 4Q avg 75.8%
Percentage of long-stay residents who lose too much weight	7.1%	5.2% 1.9 pts worse	5.4% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.4% · Q3 11.6% · Q4 5.3% · 4Q avg 7.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.5%	19.2% 3.7 pts better	19.6% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 13.9% · Q3 15.9% · Q4 16.7% · 4Q avg 15.5%
Percentage of long-stay residents who received an antipsychotic medication	25.3%	22.5% 2.8 pts worse	16.7% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 28.4% · Q3 23.1% · Q4 22.5% · 4Q avg 25.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	8.6%	17.7% 9.1 pts better	16.3% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 13.5% · Q3 4.1% · Q4 1.3% · 4Q avg 8.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.1%	17.6% 9.5 pts better	14.9% 6.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 7.7% · Q3 6.9% · Q4 4.1% · 4Q avg 8.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	1.0% 0.6 pts worse	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 1.1% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.3%	2.0% 0.3 pts worse	1.7% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.0% · Q3 2.6% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.1%	21.7% 7.6 pts better	19.8% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 19.2% · Q3 11.9% · Q4 11.9% · 4Q avg 14.1%
Percentage of long-stay residents with pressure ulcers	3.8%	4.6% 0.8 pts better	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 4.4% · Q4 4.4% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	36.3%	77.1% 40.8 pts worse	81.7% 45.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 51.8% · Q3 41.5% · Q4 25.6% · 4Q avg 36.3%
Percentage of short-stay residents who had an outpatient emergency department visit	5.2%	11.8% 6.6 pts better	12.0% 6.8 pts better	Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.9% · Expected 12.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.3%	1.3% 1 pts worse	1.6% 0.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.4% · Q3 3.3% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	52.6%	77.7% 25.1 pts worse	79.7% 27.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 52.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.4%	25.8% 0.4 pts better	23.9% 1.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 25.5% · Expected 23.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-02 · Fire 2025-04-02

18 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

8 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Cycle 2 Health 2024-04-22 · Fire 2024-04-22

34 health deficiencies

Top issue: Resident Rights (8 deficiencies)

7 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 3 Health 2023-02-02 · Fire 2023-02-02

31 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-02

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-23

F · Potential for more than minimal harm 2025-04-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-23

F · Potential for more than minimal harm 2024-04-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-06-04

F · Potential for more than minimal harm 2024-04-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-04

F · Potential for more than minimal harm 2024-04-22

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-06-04

F · Potential for more than minimal harm 2024-04-22

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-06-04

F · Potential for more than minimal harm 2024-04-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-04

F · Potential for more than minimal harm 2024-04-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-06-04

E · Potential for more than minimal harm 2024-04-22

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-06-04

D · Potential for more than minimal harm 2023-02-02

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-02

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-02

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-02

K521 · Services Deficiencies

Fire Safety

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

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-02

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-03-29

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-04-02

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-05-08

E · Potential for more than minimal harm 2025-04-02

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 2025-05-08

E · Potential for more than minimal harm 2025-04-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F550 · Resident Rights Deficiencies

Health

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

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

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 2025-05-08

D · Potential for more than minimal harm 2025-04-02

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 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

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 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

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 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

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 2025-05-08

D · Potential for more than minimal harm 2025-04-02

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 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-02

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-05-08

B · Minimal harm 2025-04-02

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-05-08

F · Potential for more than minimal harm 2024-04-22

F725 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

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 2024-05-29

E · Potential for more than minimal harm 2024-04-22

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 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

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 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

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 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

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 2024-05-29

E · Potential for more than minimal harm 2024-04-22

F887 · Infection Control Deficiencies

Health

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F559 · Resident Rights Deficiencies

Health

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

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 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-04-22

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-05-29

B · Minimal harm 2024-04-22

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-05-29

F · Potential for more than minimal harm 2024-01-26

F727 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2024-02-23

F · Potential for more than minimal harm 2024-01-26

F836 · Administration Deficiencies

Health

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Corrected 2024-02-23

D · Potential for more than minimal harm 2024-01-26

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 2024-02-23

D · Potential for more than minimal harm 2024-01-26

F867 · Administration Deficiencies

Health

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

Corrected 2024-02-23

E · Potential for more than minimal harm 2023-11-29

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 2024-01-10

D · Potential for more than minimal harm 2023-11-29

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 2024-01-10

E · Potential for more than minimal harm 2023-08-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-05

E · Potential for more than minimal harm 2023-08-01

F921 · Environmental Deficiencies

Health

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

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-08-01

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-04-27

F727 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2023-06-08

F · Potential for more than minimal harm 2023-04-27

F836 · Administration Deficiencies

Health

Corrected 2023-06-08

F · Potential for more than minimal harm 2023-04-27

F867 · Administration Deficiencies

Health

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

Corrected 2023-06-08

E · Potential for more than minimal harm 2023-04-27

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-06-08

D · Potential for more than minimal harm 2023-04-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-08

E · Potential for more than minimal harm 2023-02-02

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 2023-03-13

E · Potential for more than minimal harm 2023-02-02

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-03-13

E · Potential for more than minimal harm 2023-02-02

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-13

E · Potential for more than minimal harm 2023-02-02

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 2023-03-13

E · Potential for more than minimal harm 2023-02-02

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

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 2023-03-13

D · Potential for more than minimal harm 2023-02-02

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 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

F758 · Pharmacy Service Deficiencies

Health

Corrected 2023-03-13

D · Potential for more than minimal harm 2023-02-02

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 2023-03-13

D · Potential for more than minimal harm 2023-02-02