Cycle 1
Health 2025-09-05 · Fire 2025-09-05
48 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cambridge, MD
Mallard Bay Nursing And Rehab
1-star overall rating with 1-star inspections with 48 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
520 Glenburn Avenue, Cambridge, MD
(410) 228-9191
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Key Health Management
Operator or chain grouping
Approved since
1989-03-17
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
0.54
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
2.85
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,133
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.17
Baseline 15.29% · Performance 18.11% · Measure score 7.17 · Achievement 7.17 · Improvement 0
Healthcare-associated infections
0
Baseline 5.33% · Performance 7.82% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 71.19% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.43 hours · Performance 2.99 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.92% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 279 · Observed rate 15.41% · Lower 95% interval 9.76% |
| Discharge to community | 57.75% |
50.57%
7.2 pts better
|
Better than the National Rate · Eligible stays 270 · Observed rate 48.15% · Lower 95% interval 52.26% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.74% |
95.27%
3.5 pts better
|
Numerator 157 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 45.19% |
53.69%
8.5 pts worse
|
Numerator 47 · Denominator 104 |
| Discharge mobility score | 25.96% |
50.94%
25 pts worse
|
Numerator 27 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 5.66% |
2.29%
3.4 pts worse
|
Numerator 9 · Denominator 159 · Adjusted rate 4.69% |
| Healthcare-associated infections requiring hospitalization | 7.82% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 185 · Observed rate 9.19% · Lower 95% interval 5.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 159 |
| Staff flu vaccination coverage | 35.03% |
42%
7 pts worse
|
Numerator 62 · Denominator 177 |
| Discharge function score | 35.58% |
56.45%
20.9 pts worse
|
Numerator 37 · Denominator 104 |
| Transfer of health information to provider | 98.57% |
95.95%
2.6 pts better
|
Numerator 69 · Denominator 70 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.3
1 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.4 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.5% |
91.9%
22.4 pts worse
|
93.4%
23.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 77.8% · Q3 89.9% · Q4 73.4% · 4Q avg 69.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
96.6%
4.3 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
2.3%
1.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.7% · Q3 4.5% · Q4 4.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.5% |
21.4%
10.1 pts worse
|
11.4%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 23.9% · Q3 35.7% · Q4 43.0% · 4Q avg 31.5% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.7%
0.6 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 8.9% · Q3 5.8% · Q4 3.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
16.1%
6 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 22.5% · Q3 23.9% · Q4 24.7% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
15.3%
1.9 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 13.1% · Q3 14.5% · Q4 21.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 46.2% |
26.6%
19.6 pts worse
|
16.3%
29.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 44.9% · Q4 21.7% · 4Q avg 46.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.1% |
22.9%
11.2 pts worse
|
14.9%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 34.2% · Q3 33.3% · Q4 23.5% · 4Q avg 34.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
0.7%
1.6 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.1% · Q3 2.0% · Q4 0.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.5%
0.3 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 1.1% · Q4 3.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
25.4%
6 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 45.0% · Q3 22.5% · Q4 30.7% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.3%
0.6 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.3% · Q3 8.4% · Q4 5.1% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.1% |
78.4%
33.3 pts worse
|
81.7%
36.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 56.0% · Q3 71.7% · Q4 41.9% · 4Q avg 45.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
9.9%
2.6 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.7% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.0% |
80.6%
8.6 pts worse
|
79.7%
7.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.6% |
21.2%
8.6 pts better
|
23.9%
11.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 13.2% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-26 · Fire 2022-08-26
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2018-12-04 · Fire 2018-12-04
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-16
E · Potential for more than minimal harm
2025-09-05
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 2026-01-16
E · Potential for more than minimal harm
2025-09-05
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 2026-01-16
D · Potential for more than minimal harm
2025-09-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-09-05
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 2026-01-16
D · Potential for more than minimal harm
2025-09-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-09-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2026-01-16
F · Potential for more than minimal harm
2022-08-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-20
F · Potential for more than minimal harm
2022-08-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-08-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-20
D · Potential for more than minimal harm
2022-08-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-20
D · Potential for more than minimal harm
2022-08-26
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 2022-10-20
D · Potential for more than minimal harm
2022-08-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-20
F · Potential for more than minimal harm
2018-12-04
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-04-05
F · Potential for more than minimal harm
2018-12-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-04-05
F · Potential for more than minimal harm
2018-12-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-04-05
F · Potential for more than minimal harm
2018-12-04
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-04-05
E · Potential for more than minimal harm
2018-12-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-04-05
E · Potential for more than minimal harm
2018-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-04-05
D · Potential for more than minimal harm
2018-12-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-04-05
D · Potential for more than minimal harm
2018-12-04
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 2019-04-05
D · Potential for more than minimal harm
2018-12-04
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 2019-04-05
D · Potential for more than minimal harm
2018-12-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-04-05
D · Potential for more than minimal harm
2018-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-17
E · Potential for more than minimal harm
2026-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
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 2026-02-17
D · Potential for more than minimal harm
2026-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2026-02-17
D · Potential for more than minimal harm
2026-01-08
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 2026-02-17
D · Potential for more than minimal harm
2025-10-22
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-10-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-10-22
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 2025-12-03
D · Potential for more than minimal harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2025-09-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2025-09-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-05
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2025-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-04-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-30
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 2025-06-11
E · Potential for more than minimal harm
2025-04-30
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 2025-06-11
E · Potential for more than minimal harm
2025-04-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-30
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 2025-06-11
E · Potential for more than minimal harm
2025-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-30
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 2025-06-11
E · Potential for more than minimal harm
2025-04-30
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-11-15
E · Potential for more than minimal harm
2025-04-30
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
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 2025-06-11
D · Potential for more than minimal harm
2022-08-26
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 2022-10-26
D · Potential for more than minimal harm
2022-08-26
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 2022-10-26
D · Potential for more than minimal harm
2022-08-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-08-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-08-26
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-08-26
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 2022-10-26
F · Potential for more than minimal harm
2018-12-04
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-01-11
F · Potential for more than minimal harm
2018-12-04
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 2019-01-11
E · Potential for more than minimal harm
2018-12-04
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 2019-01-11
E · Potential for more than minimal harm
2018-12-04
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 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
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 2019-01-11
D · Potential for more than minimal harm
2018-12-04
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 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
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 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
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 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-11
Penalties and ownership
What sits behind the stars
Ownership
Hirth, Yechiel
Operational/Managerial Control · Individual
Howard, Daniel
Operational/Managerial Control · Individual
White, Elliott
Operational/Managerial Control · Individual
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