Cycle 1
Health 2025-04-17 · Fire 2025-04-17
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Philadelphia, PA
Immaculatemarycenter For Rehabilitation&Healthcare
1-star overall rating with 1-star inspections with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2990 Holme Avenue, Philadelphia, PA
(215) 335-2100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
296
Certified beds
Average residents
265
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Center Management Group
Operator or chain grouping
Approved since
1976-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 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
0.28
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,652
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.06% · Performance 22.41% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.31% · Performance 11.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 51.09% · Performance 65.36% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.91
Baseline 3.85 hours · Performance 3.34 hours · Measure score 0.91 · Achievement 0.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.69% |
10.72%
3 pts worse
|
No Different than the National Rate · Eligible stays 292 · Observed rate 16.78% · Lower 95% interval 10.36% |
| Discharge to community | 42.65% |
50.57%
7.9 pts worse
|
Worse than the National Rate · Eligible stays 279 · Observed rate 34.05% · Lower 95% interval 36.8% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 80.1% |
95.27%
15.2 pts worse
|
Numerator 334 · Denominator 417 |
| Falls with major injury | 0.48% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 417 |
| Discharge self-care score | 27.15% |
53.69%
26.5 pts worse
|
Numerator 41 · Denominator 151 |
| Discharge mobility score | 29.14% |
50.94%
21.8 pts worse
|
Numerator 44 · Denominator 151 |
| Pressure ulcers or injuries, new or worsened | 0.72% |
2.29%
1.6 pts better
|
Numerator 3 · Denominator 417 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 11.99% |
7.12%
4.9 pts worse
|
Worse than the National Rate · Eligible stays 214 · Observed rate 15.89% · Lower 95% interval 9.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 364 |
| Staff flu vaccination coverage | 9.52% |
42%
32.5 pts worse
|
Numerator 52 · Denominator 546 |
| Discharge function score | 39.74% |
56.45%
16.7 pts worse
|
Numerator 60 · Denominator 151 |
| Transfer of health information to provider | 97.42% |
95.95%
1.5 pts better
|
Numerator 189 · Denominator 194 |
| Transfer of health information to patient | 95.92% |
96.28%
0.4 pts worse
|
Numerator 94 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 5.13% |
25.2%
20.1 pts worse
|
Numerator 12 · Denominator 234 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
86.9%
6.5 pts worse
|
93.4%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 77.9% · Q3 75.7% · Q4 77.1% · 4Q avg 80.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
93.5%
1 pts worse
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.6% · Q3 3.2% · Q4 2.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
6.5%
2.3 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 5.1% · Q3 3.5% · Q4 5.9% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
6.5%
4.4 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 10.1% · Q3 11.5% · Q4 14.8% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.9%
4.5 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 15.5% · Q3 13.3% · Q4 17.0% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
18.7%
4.2 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 17.0% · Q3 15.8% · Q4 12.3% · 4Q avg 14.5% · 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 | 6.2% |
19.6%
13.4 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.9% · Q3 10.4% · Q4 3.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
18.3%
11.1 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.3% · Q3 5.6% · Q4 7.1% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.4% · Q3 0.0% · Q4 0.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.1% |
1.7%
1.6 pts better
|
1.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
26.4%
1.5 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 26.7% · Q3 24.6% · Q4 31.7% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.3%
0.2 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.6% · Q3 7.0% · Q4 7.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.6% |
68.9%
22.3 pts worse
|
81.7%
35.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.8% · Q2 48.9% · Q3 43.1% · Q4 38.5% · 4Q avg 46.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
9.8%
2.6 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.7% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.4% · Q3 0.9% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.5% |
68.7%
6.2 pts worse
|
79.7%
17.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
23.1%
9.9 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 35.5% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-17 · Fire 2024-06-17
17 health deficiencies
Top issue: Resident Rights (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-08-28 · Fire 2023-08-28
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-17
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-01
E · Potential for more than minimal harm
2024-06-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-18
C · Minimal harm
2024-06-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-18
E · Potential for more than minimal harm
2023-08-28
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-08-28
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 2023-10-23
E · Potential for more than minimal harm
2023-08-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-08-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-08-28
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 2023-10-23
D · Potential for more than minimal harm
2023-08-28
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 2023-10-23
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-03
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 2025-10-23
D · Potential for more than minimal harm
2025-10-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-10-03
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 2025-10-23
D · Potential for more than minimal harm
2025-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-15
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-15
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-08-08
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 2025-09-03
E · Potential for more than minimal harm
2025-04-17
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 2025-05-14
E · Potential for more than minimal harm
2025-04-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-04-17
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 2025-05-14
E · Potential for more than minimal harm
2025-04-17
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 2025-05-14
E · Potential for more than minimal harm
2025-04-17
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-17
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 2025-05-14
D · Potential for more than minimal harm
2025-04-17
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 2025-05-14
D · Potential for more than minimal harm
2025-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-17
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 2025-05-14
E · Potential for more than minimal harm
2025-02-03
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-02-20
E · Potential for more than minimal harm
2024-06-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
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 2024-07-09
D · Potential for more than minimal harm
2024-06-17
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 2024-07-09
D · Potential for more than minimal harm
2024-06-17
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 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-17
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 2024-07-09
D · Potential for more than minimal harm
2024-06-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-16
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 2024-06-17
D · Potential for more than minimal harm
2024-04-18
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 2024-06-17
D · Potential for more than minimal harm
2024-04-18
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 2024-06-17
D · Potential for more than minimal harm
2024-04-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-17
E · Potential for more than minimal harm
2023-08-28
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 2023-09-21
D · Potential for more than minimal harm
2023-08-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-28
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-28
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 2023-09-21
D · Potential for more than minimal harm
2023-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-28
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 2023-09-21
D · Potential for more than minimal harm
2023-08-28
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 2023-09-21
D · Potential for more than minimal harm
2023-08-28
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 2023-09-21
D · Potential for more than minimal harm
2023-08-28
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 2023-09-21
D · Potential for more than minimal harm
2023-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-07-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
Ownership
Gros, Charles-Edouard
5% Or Greater Direct Ownership Interest · Individual
Boehm, Caroline
5% Or Greater Direct Ownership Interest · Individual
Allen, Daniel
Operational/Managerial Control · Individual
Back, Menachem
Operational/Managerial Control · Individual
Greystone Funding Company LLC
5% Or Greater Mortgage Interest · Organization
Hanstein, Patricia
Operational/Managerial Control · Individual
Kimmel, Brian
Operational/Managerial Control · Individual
Klein, Baruch
Operational/Managerial Control · Individual
Levi, Shlomo
Operational/Managerial Control · Individual
Petroski, Edward
Operational/Managerial Control · Individual
Spector, Larry
Operational/Managerial Control · Individual
Vinitsky, Avrohom
Operational/Managerial Control · Individual
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