Cycle 1
Health 2025-01-30 · Fire 2025-01-30
31 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lincoln, IL
Lincoln Village Healthcare
1-star overall rating with 1-star inspections with abuse icon flag with $151,198 in total fines with 31 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2202 North Kickapoo Street, Lincoln, IL
(217) 735-1538
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Generations Healthcare
Operator or chain grouping
Approved since
1992-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 4 overall / 3 health / 3 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
0.55
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.42
CMS adjusted total nurse staffing hours
Case-mix index
2.19
Higher values indicate more complex resident acuity
RN turnover
88%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,394
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.87
Baseline 67.11% · Performance 61.33% · Measure score 0.87 · Achievement 0.57 · Improvement 0.87
Adjusted total nurse staffing
0.29
Baseline 1.96 hours · Performance 2.26 hours · Measure score 0.29 · Achievement 0 · Improvement 0.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.51% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 33.33% · Lower 95% interval 9.72% |
| Discharge to community | 37.92% |
50.57%
12.6 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 17.86% · Lower 95% interval 22.44% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.23% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 81 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 40 · Denominator 80 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 7.6 |
2.3
5.3 pts worse
|
1.8
5.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 7.6 · Observed 6.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
89.6%
1.5 pts better
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.7% · Q2 97.3% · Q3 98.6% · Q4 98.6% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
91.6%
5.8 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.5% · Q3 8.3% · Q4 5.6% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 62.7% |
50.3%
12.4 pts worse
|
11.4%
51.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.4% · Q2 62.7% · Q3 56.9% · Q4 70.0% · 4Q avg 62.7% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
6.5%
2 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.6% · Q3 15.9% · Q4 6.3% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
18.5%
8.1 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 23.9% · Q3 25.0% · Q4 28.1% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
22.8%
1.2 pts better
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 20.4% · Q3 20.8% · Q4 26.0% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.1%
0.3 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.8% |
17.2%
16.6 pts worse
|
16.3%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 44.6% · Q3 44.2% · Q4 24.2% · 4Q avg 33.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
15.0%
5.8 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 34.5% · Q3 21.6% · Q4 10.0% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.1%
1.5 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.2% · Q3 2.4% · Q4 4.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
1.7%
1.9 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.0% · Q3 2.8% · Q4 4.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.7% |
21.3%
10.6 pts better
|
19.8%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 16.5% · Q3 10.7% · Q4 7.3% · 4Q avg 10.7% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.2%
3 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.8% · Q3 6.1% · Q4 11.8% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.7% |
68.8%
10.1 pts worse
|
81.7%
23 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 58.8% · Q3 78.0% · Q4 69.2% · 4Q avg 58.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
14.0%
8.3 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 25.8% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
2.3%
2.6 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q3 4.5% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.6% |
63.0%
0.6 pts better
|
79.7%
16.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
26.2%
3.3 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 35.5% · Expected 28.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
32 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-03-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-19
F · Potential for more than minimal harm
2023-04-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-04-19
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 2023-05-17
F · Potential for more than minimal harm
2023-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-24
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 2026-02-04
D · Potential for more than minimal harm
2026-01-21
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 2026-02-02
G · Actual harm
2025-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-26
G · Actual harm
2025-07-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-10
G · Actual harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-20
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 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-10
D · Potential for more than minimal harm
2025-07-02
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 2025-07-19
D · Potential for more than minimal harm
2025-07-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-19
D · Potential for more than minimal harm
2025-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-19
G · Actual harm
2025-05-15
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 2025-06-09
F · Potential for more than minimal harm
2025-05-15
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 2025-06-09
E · Potential for more than minimal harm
2025-05-15
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 2025-06-09
E · Potential for more than minimal harm
2025-05-15
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 2025-06-24
D · Potential for more than minimal harm
2025-05-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-03-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-27
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 2025-04-14
E · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-21
C · Minimal harm
2025-01-30
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 2025-02-21
F · Potential for more than minimal harm
2024-12-26
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-01-19
D · Potential for more than minimal harm
2024-12-26
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 2025-01-19
D · Potential for more than minimal harm
2024-12-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-19
D · Potential for more than minimal harm
2024-12-26
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 2025-01-19
E · Potential for more than minimal harm
2024-11-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-13
G · Actual harm
2024-04-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-04-25
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-03-28
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 2024-04-20
E · Potential for more than minimal harm
2024-03-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-20
E · Potential for more than minimal harm
2024-03-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-28
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 2024-04-20
D · Potential for more than minimal harm
2024-03-28
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 2024-04-20
C · Minimal harm
2024-03-28
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-04-20
G · Actual harm
2024-03-23
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 2024-04-14
D · Potential for more than minimal harm
2024-01-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-11
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 2024-01-26
D · Potential for more than minimal harm
2024-01-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-26
G · Actual harm
2023-12-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-08
G · Actual harm
2023-12-14
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 2024-01-08
D · Potential for more than minimal harm
2023-12-14
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 2024-01-08
D · Potential for more than minimal harm
2023-11-28
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-10-25
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 2023-11-11
D · Potential for more than minimal harm
2023-10-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-11
F · Potential for more than minimal harm
2023-10-03
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 2023-10-22
F · Potential for more than minimal harm
2023-10-03
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-10-22
F · Potential for more than minimal harm
2023-10-03
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-10-22
F · Potential for more than minimal harm
2023-10-03
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 2023-10-22
D · Potential for more than minimal harm
2023-10-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-10-03
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 2023-10-22
D · Potential for more than minimal harm
2023-10-03
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 2023-10-22
D · Potential for more than minimal harm
2023-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-22
F · Potential for more than minimal harm
2023-09-03
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-09-03
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 2023-09-22
D · Potential for more than minimal harm
2023-09-03
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 2023-09-22
D · Potential for more than minimal harm
2023-09-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-09-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-04-19
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 2023-05-17
F · Potential for more than minimal harm
2023-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-19
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 2023-05-17
E · Potential for more than minimal harm
2023-04-19
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 2023-05-17
D · Potential for more than minimal harm
2023-04-19
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 2023-05-17
D · Potential for more than minimal harm
2023-04-19
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 2023-05-17
D · Potential for more than minimal harm
2023-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-19
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-17
Penalties and ownership
What sits behind the stars
$63,720
2025-07-02
Fine
Fine · fine $63,720
Fine
$0
2025-05-15
Payment Denial
Payment Denial · denial start 2025-06-14 · 10 days
10 day denial
$22,025
2024-03-23
Fine
Fine · fine $22,025
Fine
$40,337
2024-03-23
Fine
Fine · fine $40,337
Fine
$0
2024-03-23
Payment Denial
Payment Denial · denial start 2024-04-20 · 24 days
24 day denial
$25,116
2023-11-28
Fine
Fine · fine $25,116
Fine
$0
2023-11-28
Payment Denial
Payment Denial · denial start 2024-01-13 · 13 days
13 day denial
Ownership
Atied Associates LLC
5% Or Greater Direct Ownership Interest · Organization
Goldfinger Ray, Helen
5% Or Greater Direct Ownership Interest · Individual
West, Brook
Operational/Managerial Control · Individual
West, Brook
W-2 Managing Employee · Individual
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#3
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