Cycle 1
Health 2024-09-23 · Fire 2024-09-23
57 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
18 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Silver Spring, MD
Layhill Nursing And Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with $153,596 in total fines with 57 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
3227 Bel Pre Road, Silver Spring, MD
(301) 871-2000
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
129
Certified beds
Average residents
124
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1987-11-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 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
0.70
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,250
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.09
Baseline 22.43% · Performance 22.11% · Measure score 0.09 · Achievement 0 · Improvement 0.09
Healthcare-associated infections
0
Baseline 7.36% · Performance 9.18% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.79
Baseline 46.67% · Performance 52.29% · Measure score 2.79 · Achievement 2.79 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.94 hours · Performance 2.89 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 17.48% |
10.72%
6.8 pts worse
|
Worse than the National Rate · Eligible stays 378 · Observed rate 21.96% · Lower 95% interval 14.72% |
| Discharge to community | 48.84% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 377 · Observed rate 40.32% · Lower 95% interval 42.91% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 62.06% |
95.27%
33.2 pts worse
|
Numerator 157 · Denominator 253 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 253 |
| Discharge self-care score | 52.38% |
53.69%
1.3 pts worse
|
Numerator 66 · Denominator 126 |
| Discharge mobility score | 45.24% |
50.94%
5.7 pts worse
|
Numerator 57 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 6.32% |
2.29%
4 pts worse
|
Numerator 16 · Denominator 253 · Adjusted rate 5.1% |
| Healthcare-associated infections requiring hospitalization | 9.18% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 237 · Observed rate 10.97% · Lower 95% interval 6.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 53.74% |
42%
11.7 pts better
|
Numerator 79 · Denominator 147 |
| Discharge function score | 48.41% |
56.45%
8 pts worse
|
Numerator 61 · Denominator 126 |
| Transfer of health information to provider | 94.79% |
95.95%
1.2 pts worse
|
Numerator 91 · Denominator 96 |
| Transfer of health information to patient | 85.59% |
96.28%
10.7 pts worse
|
Numerator 95 · Denominator 111 |
| Resident COVID-19 vaccinations up to date | 22.69% |
25.2%
2.5 pts worse
|
Numerator 27 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
91.9%
7.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.7% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.8% |
96.6%
10.8 pts worse
|
95.5%
9.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.3%
0.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 1.2% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.3% |
21.4%
38.9 pts worse
|
11.4%
48.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.9% · Q2 56.5% · Q3 64.5% · Q4 68.3% · 4Q avg 60.3% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.7%
3 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.5% · Q3 2.7% · Q4 1.1% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.9% |
16.1%
11.2 pts better
|
19.6%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.4% · Q3 5.1% · Q4 3.4% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
15.3%
1.9 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 16.0% · Q3 16.7% · Q4 20.0% · 4Q avg 17.2% · 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 | 9.8% |
26.6%
16.8 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 6.7% · Q3 6.5% · Q4 0.0% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.1% |
22.9%
14.8 pts better
|
14.9%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 7.8% · Q3 7.2% · Q4 5.4% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.5%
0.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 1.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
25.4%
1 pts better
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 23.8% · Q3 35.1% · Q4 22.9% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 11.6% |
6.3%
5.3 pts worse
|
5.1%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 11.5% · Q3 9.6% · Q4 11.5% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
78.4%
15.2 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 94.7% · Q3 95.0% · Q4 91.2% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
9.9%
0.7 pts worse
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 11.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.7% · Q3 0.6% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
80.6%
14.2 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
21.2%
0.9 pts worse
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 23.2% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-27 · Fire 2019-09-27
31 health deficiencies
Top issue: Resident Rights (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-10-16 · Fire 2018-10-16
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-09-23
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-09-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-09-23
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-09-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-18
D · Potential for more than minimal harm
2019-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-05
C · Minimal harm
2019-09-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2020-03-05
C · Minimal harm
2019-09-27
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 2020-03-05
C · Minimal harm
2019-09-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-03-05
C · Minimal harm
2019-09-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-05
B · Minimal harm
2019-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-03-05
D · Potential for more than minimal harm
2018-10-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-11-24
D · Potential for more than minimal harm
2018-10-16
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 2018-11-24
C · Minimal harm
2018-10-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2018-11-24
C · Minimal harm
2018-10-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-11-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-06
E · Potential for more than minimal harm
2025-10-09
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 2025-12-10
E · Potential for more than minimal harm
2025-10-09
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 2025-12-10
D · Potential for more than minimal harm
2025-10-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-10-09
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-10-09
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 2025-12-10
D · Potential for more than minimal harm
2025-10-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-10-09
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 2025-12-10
D · Potential for more than minimal harm
2025-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-10-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-10-09
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 2025-12-10
K · Immediate jeopardy
2024-09-23
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 2024-11-18
F · Potential for more than minimal harm
2024-09-23
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 2024-11-18
F · Potential for more than minimal harm
2024-09-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-23
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-09-23
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 2024-11-18
E · Potential for more than minimal harm
2024-09-23
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 2025-01-15
E · Potential for more than minimal harm
2024-09-23
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 2024-11-18
E · Potential for more than minimal harm
2024-09-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-09-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-09-23
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-09-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-09-23
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.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-09-23
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2025-01-15
D · Potential for more than minimal harm
2024-09-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-09-23
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
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 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-23
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-09-23
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-15
G · Actual harm
2024-06-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-26
G · Actual harm
2024-06-18
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 2024-07-26
E · Potential for more than minimal harm
2024-06-18
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 2024-07-26
E · Potential for more than minimal harm
2024-06-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-06-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
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 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-07-26
F · Potential for more than minimal harm
2019-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-10
E · Potential for more than minimal harm
2019-09-27
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 2019-11-10
E · Potential for more than minimal harm
2019-09-27
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 2019-11-10
D · Potential for more than minimal harm
2019-09-27
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 2019-11-10
D · Potential for more than minimal harm
2019-09-27
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-09-27
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 2019-11-10
D · Potential for more than minimal harm
2019-09-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-11-10
E · Potential for more than minimal harm
2018-10-16
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 2018-11-29
E · Potential for more than minimal harm
2018-10-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-11-29
E · Potential for more than minimal harm
2018-10-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-11-29
E · Potential for more than minimal harm
2018-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-11-29
E · Potential for more than minimal harm
2018-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-10-16
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 2018-11-29
D · Potential for more than minimal harm
2018-10-16
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 2018-11-29
D · Potential for more than minimal harm
2018-10-16
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 2018-11-29
D · Potential for more than minimal harm
2018-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-10-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-10-16
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 2018-11-29
D · Potential for more than minimal harm
2018-10-16
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 2018-11-29
D · Potential for more than minimal harm
2018-10-16
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 2018-11-29
C · Minimal harm
2018-10-16
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 2018-11-29
B · Minimal harm
2018-10-16
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-11-29
B · Minimal harm
2018-10-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-11-29
Penalties and ownership
What sits behind the stars
$100,523
2024-09-23
Fine
Fine · fine $100,523
Fine
$0
2024-09-23
Payment Denial
Payment Denial · denial start 2025-01-01 · 20 days
20 day denial
$53,073
2024-06-18
Fine
Fine · fine $53,073
Fine
Ownership
Thunder Health Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Birnbaum, Israel
5% Or Greater Indirect Ownership Interest · Individual
Netzer, Michele
5% Or Greater Indirect Ownership Interest · Individual
Kohn, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Rma Equity LLC
5% Or Greater Indirect Ownership Interest · Organization
Birnbaum, Israel
W-2 Managing Employee · Individual
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