Cycle 1
Health 2025-05-22 · Fire 2025-05-22
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Sparta, NC
Lotus Village Center for Nursing and Rehabilitatio
1-star overall rating with 1-star inspections with $418,422 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
179 Combs Street, Sparta, NC
(336) 372-2441
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1987-06-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
94 facilities
Chain averages 2 overall / 3 health / 2 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
0.30
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.98
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
0.78
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,462
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9896
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
5.68
Baseline 77.78% · Performance 45.07% · Measure score 5.68 · Achievement 4.55 · Improvement 5.68
Adjusted total nurse staffing
1.54
Baseline 3.63 hours · Performance 3.52 hours · Measure score 1.54 · Achievement 1.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 6.32% |
| Discharge to community | 42.04% |
50.57%
8.5 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 33.33% · Lower 95% interval 29.37% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 85.71% |
95.27%
9.6 pts worse
|
Numerator 18 · Denominator 21 |
| Falls with major injury | 9.52% |
0.77%
8.8 pts worse
|
Numerator 2 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · 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 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 3.64% |
42%
38.4 pts worse
|
Numerator 4 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · 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 | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
1.8
2.1 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
91.5%
2.5 pts worse
|
93.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 96.9% · Q3 90.8% · Q4 74.6% · 4Q avg 89.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.7% |
3.6%
4.1 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.7% · Q3 9.2% · Q4 7.5% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
4.8%
1.6 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.3% · Q3 3.5% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 17.7% |
7.2%
10.5 pts worse
|
5.4%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 22.6% · Q3 22.8% · Q4 11.9% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.0% |
21.6%
23.4 pts worse
|
19.6%
25.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.1% · Q2 46.9% · Q3 44.3% · Q4 43.5% · 4Q avg 45.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.1% |
15.0%
12.1 pts worse
|
16.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 27.3% · Q3 25.0% · Q4 30.2% · 4Q avg 27.1% · 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 | 33.7% |
21.5%
12.2 pts worse
|
16.3%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 17.2% · 4Q avg 33.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.7% |
16.8%
7.9 pts worse
|
14.9%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 18.3% · Q3 33.3% · Q4 45.2% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
21.2%
2.7 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 28.6% · Q3 20.2% · Q4 24.8% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.0%
1.9 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.5% · Q3 5.9% · Q4 2.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.7% |
79.9%
21.2 pts worse
|
81.7%
23 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 88.0% · Q3 51.0% · Q4 24.1% · 4Q avg 58.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 30.5% |
13.2%
17.3 pts worse
|
12.0%
18.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 32.3% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.8% |
78.1%
1.3 pts worse
|
79.7%
2.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
22.9%
0.2 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 19.4% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
25 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-05-22
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 2025-09-01
D · Potential for more than minimal harm
2025-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-01
D · Potential for more than minimal harm
2024-02-22
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 2024-06-05
D · Potential for more than minimal harm
2024-02-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-02-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-05
E · Potential for more than minimal harm
2022-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-09-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-12-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-22
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 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
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 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
G · Actual harm
2025-04-10
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 2025-05-22
G · Actual harm
2025-04-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-22
D · Potential for more than minimal harm
2024-10-24
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 2024-10-25
J · Immediate jeopardy
2024-09-27
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 2024-09-20
D · Potential for more than minimal harm
2024-08-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-07
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 2024-08-29
D · Potential for more than minimal harm
2024-08-07
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 2024-08-29
K · Immediate jeopardy
2024-04-08
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 2024-05-04
K · Immediate jeopardy
2024-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-04
J · Immediate jeopardy
2024-04-08
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 2024-05-04
E · Potential for more than minimal harm
2024-04-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-04
F · Potential for more than minimal harm
2024-02-22
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 2024-05-04
F · Potential for more than minimal harm
2024-02-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-04
E · Potential for more than minimal harm
2024-02-22
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 2024-05-04
E · Potential for more than minimal harm
2024-02-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-04
E · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
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 2024-05-04
D · Potential for more than minimal harm
2024-02-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-04
B · Minimal harm
2024-02-22
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 2024-05-04
K · Immediate jeopardy
2023-07-12
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 2023-08-03
K · Immediate jeopardy
2023-07-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-03
J · Immediate jeopardy
2023-07-12
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 2023-08-03
D · Potential for more than minimal harm
2023-07-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-03
K · Immediate jeopardy
2022-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-28
G · Actual harm
2022-09-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-28
G · Actual harm
2022-09-14
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 2022-10-28
G · Actual harm
2022-09-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-14
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-14
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 2022-10-28
E · Potential for more than minimal harm
2022-09-14
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 2022-10-28
E · Potential for more than minimal harm
2022-09-14
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 2022-10-28
D · Potential for more than minimal harm
2022-09-14
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 2022-10-28
D · Potential for more than minimal harm
2022-09-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-14
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 2022-10-28
D · Potential for more than minimal harm
2022-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-14
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 2022-10-28
D · Potential for more than minimal harm
2022-09-14
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 2022-10-28
D · Potential for more than minimal harm
2022-09-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
$102,102
2025-04-10
Fine
Fine · fine $102,102
Fine
$0
2025-04-10
Payment Denial
Payment Denial · denial start 2025-05-08 · 36 days
36 day denial
$16,055
2024-09-27
Fine
Fine · fine $16,055
Fine
$197,071
2024-02-22
Fine
Fine · fine $197,071
Fine
$103,194
2023-07-12
Fine
Fine · fine $103,194
Fine
Ownership
Coalition Group LLC
5% Or Greater Direct Ownership Interest · Organization
Alliance Health Group LLC
Operational/Managerial Control · Organization
Edwards, Brenda
Operational/Managerial Control · Individual
Emanuel, Yosef
5% Or Greater Indirect Ownership Interest · Individual
Hc Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ppg Ee Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Shnz Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Zanziper Family Trust
5% Or Greater Indirect Ownership Interest · Organization
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#3
Galax Health And Rehab
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