Cycle 1
Health 2026-01-13 · Fire 2026-01-13
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Beloit, KS
Hilltop Lodge Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $51,652 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
815 N Independence Avenue, Beloit, KS
(785) 738-3516
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1995-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 3 overall / 2 health / 2 staffing / 3 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
0.71
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,666
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
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
0.60
Baseline 7.22% · Performance 7.66% · Measure score 0.60 · Achievement 0.60 · Improvement 0
Total nurse turnover
1.03
Baseline 50.00% · Performance 59.46% · Measure score 1.03 · Achievement 1.03 · Improvement 0
Adjusted total nurse staffing
1.72
Baseline 3.75 hours · Performance 3.57 hours · Measure score 1.72 · Achievement 1.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.54% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 15.63% · Lower 95% interval 8.8% |
| Discharge to community | 42% |
50.57%
8.6 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 37.21% · Lower 95% interval 29.73% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 42 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 20 · Denominator 32 |
| Discharge mobility score | 53.13% |
50.94%
2.2 pts better
|
Numerator 17 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 7.66% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 39.8% |
42%
2.2 pts worse
|
Numerator 39 · Denominator 98 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 19 · 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 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 46.8% |
91.8%
45 pts worse
|
93.4%
46.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.2% · Q2 52.4% · Q3 46.3% · Q4 39.3% · 4Q avg 46.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.2% |
95.5%
27.3 pts worse
|
95.5%
27.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 68.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
4.4%
3.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
5.6%
3.4 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 1.7% · Q4 3.8% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 13.6% |
5.0%
8.6 pts worse
|
5.4%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 7.0% · Q3 21.5% · Q4 10.7% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
23.2%
0.8 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 27.9% · Q3 21.2% · Q4 23.7% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
19.8%
4.9 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 25.5% · Q3 21.3% · Q4 22.2% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 22.6% |
18.4%
4.2 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 9.3% · Q3 35.7% · Q4 12.4% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.7% |
18.8%
5.9 pts worse
|
14.9%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 18.5% · Q3 32.8% · Q4 26.9% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.6% |
1.8%
4.8 pts worse
|
1.0%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.2% · Q3 6.3% · Q4 9.4% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
3.1%
1.9 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
23.2%
1.3 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 22.3% · Q3 34.6% · Q4 16.1% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.6%
0.2 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.9% · Q3 7.7% · Q4 3.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 26.9% |
75.6%
48.7 pts worse
|
81.7%
54.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 19.2% · 4Q avg 26.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
11.7%
1.8 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 15.0% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.2%
0.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.1% |
73.5%
50.4 pts worse
|
79.7%
56.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
23.0%
7.1 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 15.0% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
20 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2026-02-24
F · Potential for more than minimal harm
2026-01-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-24
F · Potential for more than minimal harm
2026-01-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-24
F · Potential for more than minimal harm
2024-02-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
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 2024-05-01
F · Potential for more than minimal harm
2024-02-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-02-29
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-02-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-02-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-02-29
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 2024-04-24
F · Potential for more than minimal harm
2023-04-18
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 2023-04-21
F · Potential for more than minimal harm
2022-06-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-06-16
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-08-30
F · Potential for more than minimal harm
2022-06-16
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 2022-08-30
F · Potential for more than minimal harm
2022-06-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-30
E · Potential for more than minimal harm
2022-06-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-30
E · Potential for more than minimal harm
2022-06-16
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 2022-08-30
E · Potential for more than minimal harm
2022-06-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-30
E · Potential for more than minimal harm
2022-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-13
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Not marked corrected
F · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
C · Minimal harm
2026-01-13
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Not marked corrected
J · Immediate jeopardy
2024-11-20
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 2024-10-30
F · Potential for more than minimal harm
2024-02-29
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-04-03
E · Potential for more than minimal harm
2024-02-29
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 2024-04-03
E · Potential for more than minimal harm
2024-02-29
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 2024-04-03
E · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-29
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 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-03
K · Immediate jeopardy
2024-01-09
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-29
E · Potential for more than minimal harm
2024-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-29
D · Potential for more than minimal harm
2024-01-09
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 2024-01-29
D · Potential for more than minimal harm
2023-11-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-24
G · Actual harm
2023-05-01
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 2023-05-31
D · Potential for more than minimal harm
2023-05-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-31
F · Potential for more than minimal harm
2022-06-16
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-07-20
E · Potential for more than minimal harm
2022-06-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-20
E · Potential for more than minimal harm
2022-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-20
D · Potential for more than minimal harm
2022-06-16
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 2022-07-20
D · Potential for more than minimal harm
2022-06-16
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 2022-07-20
D · Potential for more than minimal harm
2022-06-16
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 2022-07-20
D · Potential for more than minimal harm
2022-06-16
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 2022-07-20
D · Potential for more than minimal harm
2022-06-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-07-20
D · Potential for more than minimal harm
2022-06-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-07-20
D · Potential for more than minimal harm
2022-06-16
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 2022-07-20
Penalties and ownership
What sits behind the stars
$12,054
2024-11-20
Fine
Fine · fine $12,054
Fine
$16,883
2024-01-09
Fine
Fine · fine $16,883
Fine
$22,715
2023-05-01
Fine
Fine · fine $22,715
Fine
Ownership
Concannon, Craig
Operational/Managerial Control · Individual
Margulies, Zisha
Corporate Director · Individual
Mrc SNF Management LLC
Operational/Managerial Control · Organization
Shepard, Isaiah
Operational/Managerial Control · Individual
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