Cycle 1
Health 2025-05-07 · Fire 2025-05-07
32 health deficiencies
Top issue: Resident Rights (7 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Wytheville, VA
Holston Health and Rehabilitation
1-star overall rating with 1-star inspections with $111,911 in total fines with 32 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
990 Holston Rd, Wytheville, VA
(276) 228-5595
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
137
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-11-01
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
0.23
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,925
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.87
Baseline 18.35% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 0
Healthcare-associated infections
3.65
Baseline 7.30% · Performance 6.74% · Measure score 3.65 · Achievement 3.65 · Improvement 1.92
Total nurse turnover
0
Baseline 66.67% · Performance 67.83% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.28
Baseline 3.31 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 7.92% · Lower 95% interval 6.76% |
| Discharge to community | 48.54% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 45.33% · Lower 95% interval 37.74% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 90.91% |
95.27%
4.4 pts worse
|
Numerator 50 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 44.74% |
53.69%
8.9 pts worse
|
Numerator 17 · Denominator 38 |
| Discharge mobility score | 31.58% |
50.94%
19.4 pts worse
|
Numerator 12 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 3.77% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 25 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 19 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.88% |
96.28%
0.6 pts better
|
Numerator 31 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.4
1.4 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.9% · Q3 4.4% · Q4 1.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.5% |
15.7%
11.8 pts worse
|
11.4%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.2% · Q2 45.6% · Q3 15.9% · Q4 5.0% · 4Q avg 27.5% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.7%
0.9 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.1% · Q3 7.8% · Q4 2.8% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
20.2%
7.4 pts worse
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 28.4% · Q3 24.4% · Q4 33.8% · 4Q avg 27.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
15.0%
5.6 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.6% · Q3 9.8% · Q4 8.6% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 33.5% |
17.5%
16 pts worse
|
16.3%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 45.1% · Q3 35.4% · Q4 28.0% · 4Q avg 33.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
15.7%
14.9 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 38.5% · Q3 36.6% · Q4 21.2% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.6%
1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
22.2%
2.4 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 14.2% · Q3 26.1% · Q4 18.6% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.2%
2.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.4% · Q3 2.1% · Q4 3.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
74.6%
24.6 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.6% |
11.7%
9.9 pts worse
|
12.0%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 20.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
73.6%
20.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.4% |
22.0%
10.4 pts worse
|
23.9%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.4% · Observed 26.7% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-12 · Fire 2022-05-12
3 health deficiencies
Top issue: Infection Control (1 deficiency)
13 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2019-06-07 · Fire 2019-06-07
33 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-05-07
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-09-25
F · Potential for more than minimal harm
2022-05-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-30
F · Potential for more than minimal harm
2022-05-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-05-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-05-12
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-05-12
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 2022-12-30
E · Potential for more than minimal harm
2022-05-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-05-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-05-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-05-12
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 2022-10-03
E · Potential for more than minimal harm
2022-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-05-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-03
F · Potential for more than minimal harm
2019-06-07
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 2019-07-29
F · Potential for more than minimal harm
2019-06-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-07-29
E · Potential for more than minimal harm
2019-06-07
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 2019-07-29
D · Potential for more than minimal harm
2019-06-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-07-29
Inspection history
Recent health citations
K · Immediate jeopardy
2025-05-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-04
G · Actual harm
2025-05-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
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 2025-06-06
E · Potential for more than minimal harm
2025-05-07
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 2025-06-06
E · Potential for more than minimal harm
2025-05-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
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 2025-06-06
E · Potential for more than minimal harm
2025-05-07
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-07
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 2025-09-04
E · Potential for more than minimal harm
2025-05-07
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
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 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
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 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
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 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
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 2025-09-04
D · Potential for more than minimal harm
2025-05-07
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 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
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 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-07
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-06-06
F · Potential for more than minimal harm
2024-02-02
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
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 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
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 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
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 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
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 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
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 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-13
D · Potential for more than minimal harm
2022-05-12
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 2022-05-13
D · Potential for more than minimal harm
2022-05-12
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 2022-05-13
D · Potential for more than minimal harm
2022-05-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-05-13
E · Potential for more than minimal harm
2019-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-19
E · Potential for more than minimal harm
2019-06-07
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 2019-07-19
E · Potential for more than minimal harm
2019-06-07
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 2019-07-19
E · Potential for more than minimal harm
2019-06-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
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 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-19
Penalties and ownership
What sits behind the stars
$111,911
2025-05-07
Fine
Fine · fine $111,911
Fine
Ownership
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