Cycle 1
Health 2025-03-07 · Fire 2025-03-07
32 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Decatur, IL
Loft Rehab Of Decatur
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $83,223 in total fines with 32 recent health deficiencies
500 West Mckinley Avenue, Decatur, IL
(217) 875-0020
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
150
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Loft Rehabilitation And Nursing
Operator or chain grouping
Approved since
1998-07-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,496
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.66
Baseline 24.53% · Performance 20.66% · Measure score 4.66 · Achievement 1.66 · Improvement 4.66
Healthcare-associated infections
2.62
Baseline 9.20% · Performance 7.89% · Measure score 2.62 · Achievement 0 · Improvement 2.62
Total nurse turnover
3.35
Baseline 63.83% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 3.05
Adjusted total nurse staffing
0
Baseline 3.32 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.12% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 240 · Observed rate 11.67% · Lower 95% interval 8.44% |
| Discharge to community | 36.75% |
50.57%
13.8 pts worse
|
Worse than the National Rate · Eligible stays 231 · Observed rate 31.6% · Lower 95% interval 29.44% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 107 · Denominator 107 |
| Falls with major injury | 2.8% |
0.77%
2 pts worse
|
Numerator 3 · Denominator 107 |
| Discharge self-care score | 42.68% |
53.69%
11 pts worse
|
Numerator 35 · Denominator 82 |
| Discharge mobility score | 36.59% |
50.94%
14.3 pts worse
|
Numerator 30 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 7.48% |
2.29%
5.2 pts worse
|
Numerator 8 · Denominator 107 · Adjusted rate 6.44% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 8.66% · Lower 95% interval 5.36% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 77.78% |
42%
35.8 pts better
|
Numerator 70 · Denominator 90 |
| Discharge function score | 41.46% |
56.45%
15 pts worse
|
Numerator 34 · Denominator 82 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 30 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 3.57% |
25.2%
21.6 pts worse
|
Numerator 2 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.2 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.3
0.3 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
89.6%
5.7 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.9% · Q2 87.0% · Q3 81.7% · Q4 81.5% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
91.6%
4.1 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.9% · Q3 2.4% · Q4 1.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.1% |
50.3%
26.2 pts better
|
11.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 31.8% · Q3 14.1% · Q4 41.4% · 4Q avg 24.1% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.5%
2.6 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 13.9% · Q3 8.1% · Q4 5.3% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
18.5%
8 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 12.2% · Q3 9.2% · Q4 9.2% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
22.8%
16.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.2% · Q3 8.3% · Q4 5.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 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 | 39.3% |
17.2%
22.1 pts worse
|
16.3%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 31.2% · 4Q avg 39.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
15.0%
5.7 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 13.7% · Q3 29.3% · Q4 14.9% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.1%
0.3 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.4% · Q4 0.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 3.8% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.6% |
21.3%
16.3 pts worse
|
19.8%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 54.9% · Q3 23.5% · Q4 37.2% · 4Q avg 37.6% |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
5.2%
4.3 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 11.7% · Q3 9.3% · Q4 9.3% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.0% |
68.8%
22.8 pts worse
|
81.7%
35.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.0% · Q2 50.0% · Q3 38.3% · Q4 30.4% · 4Q avg 46.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
14.0%
2.2 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 15.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
2.3%
1.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 46.5% |
63.0%
16.5 pts worse
|
79.7%
33.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 46.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
26.2%
3 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 24.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-24 · Fire 2024-04-24
41 health deficiencies
Top issue: Resident Rights (14 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-14 · Fire 2023-06-14
25 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
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 2026-02-06
D · Potential for more than minimal harm
2026-01-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-02-06
G · Actual 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 2025-10-27
D · Potential for more than minimal harm
2025-10-09
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-10-27
D · Potential for more than minimal harm
2025-07-22
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 2025-08-04
D · Potential for more than minimal harm
2025-07-22
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 2025-08-04
D · Potential for more than minimal harm
2025-05-14
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 2025-05-22
J · Immediate jeopardy
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-12
G · Actual harm
2025-04-03
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 2025-04-15
J · Immediate jeopardy
2025-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-14
G · Actual harm
2025-03-07
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 2025-04-14
G · Actual harm
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-12
G · Actual harm
2025-03-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-14
G · Actual harm
2025-03-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-07
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-07
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
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 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
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 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-14
J · Immediate jeopardy
2025-02-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-25
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 2025-04-07
F · Potential for more than minimal harm
2025-02-25
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-25
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 2025-04-07
E · Potential for more than minimal harm
2024-09-10
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 2024-09-11
D · Potential for more than minimal harm
2024-08-30
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 2024-09-12
D · Potential for more than minimal harm
2024-08-30
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 2024-09-12
F · Potential for more than minimal harm
2024-08-07
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-11
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 2024-07-23
D · Potential for more than minimal harm
2024-07-11
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 2024-07-23
D · Potential for more than minimal harm
2024-06-28
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 2024-07-11
D · Potential for more than minimal harm
2024-06-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-06-28
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 2024-07-15
E · Potential for more than minimal harm
2024-06-20
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 2024-07-12
D · Potential for more than minimal harm
2024-06-20
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 2024-07-12
D · Potential for more than minimal harm
2024-06-20
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-05-31
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 2024-06-18
D · Potential for more than minimal harm
2024-05-31
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 2024-06-18
F · Potential for more than minimal harm
2024-04-24
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 2024-05-25
F · Potential for more than minimal harm
2024-04-24
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-05-25
E · Potential for more than minimal harm
2024-04-24
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 2024-05-25
E · Potential for more than minimal harm
2024-04-24
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 2024-05-25
E · Potential for more than minimal harm
2024-04-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-25
E · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
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 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-24
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-05-25
G · Actual harm
2024-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-01-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-05
E · Potential for more than minimal harm
2023-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-06
F · Potential for more than minimal harm
2023-06-14
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 2023-07-05
E · Potential for more than minimal harm
2023-06-14
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 2023-07-05
D · Potential for more than minimal harm
2023-06-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-14
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 2023-07-05
D · Potential for more than minimal harm
2023-06-14
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 2023-07-05
D · Potential for more than minimal harm
2023-06-14
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-14
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 2023-07-05
D · Potential for more than minimal harm
2023-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-14
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 2023-07-05
D · Potential for more than minimal harm
2023-05-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-31
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 2023-06-21
D · Potential for more than minimal harm
2023-05-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-10
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 2023-05-25
D · Potential for more than minimal harm
2023-05-10
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 2023-05-25
D · Potential for more than minimal harm
2023-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-25
G · Actual harm
2023-03-28
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 2023-04-25
E · Potential for more than minimal harm
2023-03-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-25
Penalties and ownership
What sits behind the stars
$0
2024-05-03
Payment Denial
Payment Denial · denial start 2024-08-03 · 40 days
40 day denial
$0
2024-04-24
Payment Denial
Payment Denial · denial start 2024-06-07 · 46 days
46 day denial
$70,184
2024-01-30
Fine
Fine · fine $70,184
Fine
$13,039
2023-03-28
Fine
Fine · fine $13,039
Fine
$0
2023-03-28
Payment Denial
Payment Denial · denial start 2023-04-25 · 71 days
71 day denial
Ownership
Aaron, Adam
5% Or Greater Direct Ownership Interest · Individual
Aaron, Daniel
5% Or Greater Direct Ownership Interest · Individual
Aaron, Michael
5% Or Greater Direct Ownership Interest · Individual
Aaron, Robert
5% Or Greater Direct Ownership Interest · Individual
Aaron, Daniel
Corporate Officer · Individual
Aaron, Daniel
W-2 Managing Employee · Individual
Aaron, Fred
Corporate Officer · Individual
Aaron, Robert
Corporate Officer · Individual
Job, Dawn
Corporate Officer · Individual
Job, Dawn
W-2 Managing Employee · Individual
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