South Bend, IN

Majestic Care Of South Bend

2-star overall rating with 1-star inspections with $116,322 in total fines with 8 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle

52654 N Ironwood Rd, South Bend, IN

(574) 277-8710

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

103

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Majestic Care

Operator or chain grouping

Approved since

1983-08-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

34 facilities

Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars

Changed ownership

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

0.58

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.58

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.46

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.61

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.16

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.08

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.56

CMS adjusted RN staffing hours

Adjusted total hours

3.52

CMS adjusted total nurse staffing hours

Case-mix index

1.40

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

75%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,787

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.13

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

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

3.40

Baseline 84.78% · Performance 61.43% · Measure score 3.40 · Achievement 0.55 · Improvement 3.40

Adjusted total nurse staffing

0.43

Baseline 2.46 hours · Performance 2.77 hours · Measure score 0.43 · Achievement 0 · Improvement 0.43

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.9%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 6.99%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.16	1.02 0.1 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 11 · 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 67
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 66
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 4 · 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	1.7	1.6 0.1 pts worse	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	1.5 0.5 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	93.6% 6 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	81.9%	95.4% 13.5 pts worse	95.5% 13.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 81.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.8%	3.8% 1 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.4% · Q3 1.8% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	13.8%	24.6% 10.8 pts better	11.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 15.8% · Q3 11.5% · Q4 22.4% · 4Q avg 13.8%
Percentage of long-stay residents who lose too much weight	10.8%	5.6% 5.2 pts worse	5.4% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 9.6% · Q3 7.8% · Q4 10.2% · 4Q avg 10.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.1%	23.5% 0.4 pts better	19.6% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 30.2% · Q3 18.9% · Q4 18.3% · 4Q avg 23.1%
Percentage of long-stay residents who received an antipsychotic medication	13.7%	14.8% 1.1 pts better	16.7% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 10.9% · Q3 13.0% · Q4 15.7% · 4Q avg 13.7% · 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	6.8%	13.3% 6.5 pts better	16.3% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.3% · 4Q avg 6.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.3%	11.7% 6.4 pts better	14.9% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 1.9% · Q3 5.8% · Q4 1.7% · 4Q avg 5.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	1.2% 0.8 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.1%	24.2% 0.1 pts better	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 23.3% · Q3 21.8% · Q4 21.8% · 4Q avg 24.1%
Percentage of long-stay residents with pressure ulcers	8.4%	4.1% 4.3 pts worse	5.1% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.2% · Q3 8.3% · Q4 10.6% · 4Q avg 8.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.7%	81.6% 14.1 pts better	81.7% 14 pts better	Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 95.7%
Percentage of short-stay residents who newly received an antipsychotic medication	9.3%	1.3% 8 pts worse	1.6% 7.7 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	12.5%	79.0% 66.5 pts worse	79.7% 67.2 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 12.5%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-19 · Fire 2025-08-19

8 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

24 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-10-04 · Fire 2024-10-04

19 health deficiencies

Top issue: Resident Rights (5 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2023-08-28 · Fire 2023-08-28

26 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-19

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

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 2025-10-03

F · Potential for more than minimal harm 2025-08-19

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 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-19

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

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 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

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 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-19

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-10-03

D · Potential for more than minimal harm 2025-08-19

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-10-03

C · Minimal harm 2025-08-19

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2025-10-03

C · Minimal harm 2025-08-19

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-10-03

F · Potential for more than minimal harm 2024-10-04

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-11-07

F · Potential for more than minimal harm 2024-10-04

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2024-11-07

F · Potential for more than minimal harm 2024-10-04

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-11-07

F · Potential for more than minimal harm 2024-10-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-07

F · Potential for more than minimal harm 2024-10-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-11-07

F · Potential for more than minimal harm 2024-10-04

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-11-07

F · Potential for more than minimal harm 2024-10-04

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 2024-11-07

E · Potential for more than minimal harm 2024-10-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-10-04

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-11-07

F · Potential for more than minimal harm 2023-08-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Not marked corrected

F · Potential for more than minimal harm 2023-08-28

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-10-26

F · Potential for more than minimal harm 2023-08-28

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-08-28

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-10-26

E · Potential for more than minimal harm 2023-08-28

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-10-26

E · Potential for more than minimal harm 2023-08-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-10-26

E · Potential for more than minimal harm 2023-08-28

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-08-28

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-10-26

E · Potential for more than minimal harm 2023-08-28

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-08-28

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-10-26

C · Minimal harm 2023-08-28

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2023-10-26

C · Minimal harm 2023-08-28

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-10-26

Inspection history

Recent health citations

F · Potential for more than minimal harm 2026-01-16

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2026-01-30

D · Potential for more than minimal harm 2026-01-16

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2026-01-30

E · Potential for more than minimal harm 2025-08-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-29

E · Potential for more than minimal harm 2025-08-19

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-08-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-08-19

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-08-19

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 2025-09-29

D · Potential for more than minimal harm 2025-08-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-29

E · Potential for more than minimal harm 2024-10-04

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-11-07

E · Potential for more than minimal harm 2024-10-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

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 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-04

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-11-07

K · Immediate jeopardy 2024-08-23

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-09-12

E · Potential for more than minimal harm 2024-08-23

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-09-12

D · Potential for more than minimal harm 2024-08-23

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-09-12

J · Immediate jeopardy 2024-07-15

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-08-08

F · Potential for more than minimal harm 2024-07-15

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 2024-09-12

E · Potential for more than minimal harm 2024-07-15

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-08-08

D · Potential for more than minimal harm 2024-07-15

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 2024-08-08

D · Potential for more than minimal harm 2024-02-20

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 2024-03-07

D · Potential for more than minimal harm 2024-02-20

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-03-07

D · Potential for more than minimal harm 2024-01-11

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 2024-01-26

D · Potential for more than minimal harm 2024-01-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-01-26

J · Immediate jeopardy 2023-10-12

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 2023-10-04

E · Potential for more than minimal harm 2023-08-28

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2023-09-30

E · Potential for more than minimal harm 2023-08-28

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-09-30

E · Potential for more than minimal harm 2023-08-28

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-09-30