Cycle 1
Health 2025-09-08 · Fire 2025-09-08
21 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Marshall, MI
Marshall Nursing and Rehabilitation Community
1-star overall rating with 1-star inspections with $105,860 in total fines with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
575 N Madison Street, Marshall, MI
(269) 781-4281
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1969-05-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,757
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.03
Baseline 23.50% · Performance 19.92% · Measure score 5.03 · Achievement 3.27 · Improvement 5.03
Healthcare-associated infections
5.29
Baseline 8.92% · Performance 6.65% · Measure score 5.29 · Achievement 3.97 · Improvement 5.29
Total nurse turnover
0.79
Baseline 66.67% · Performance 61.29% · Measure score 0.79 · Achievement 0.58 · Improvement 0.79
Adjusted total nurse staffing
2.94
Baseline 3.23 hours · Performance 3.92 hours · Measure score 2.94 · Achievement 2.94 · Improvement 2.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.31% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 16.28% · Lower 95% interval 8.64% |
| Discharge to community | 47.72% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 42.68% · Lower 95% interval 37.84% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 90.48% |
95.27%
4.8 pts worse
|
Numerator 38 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 45.83% |
53.69%
7.9 pts worse
|
Numerator 11 · Denominator 24 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 8 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 2 · Denominator 42 · Adjusted rate 5.12% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 7.89% |
8.2%
0.3 pts worse
|
Numerator 6 · Denominator 76 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 79 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 12 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 4 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
95.0%
4.2 pts worse
|
93.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 97.5% · Q3 92.3% · Q4 78.6% · 4Q avg 90.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.6% |
95.0%
6.4 pts worse
|
95.5%
6.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.1%
3.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 2.2% |
4.1%
1.9 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 3.0% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.5%
0.6 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.2% · Q3 6.7% · Q4 8.6% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
19.6%
7.6 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 9.4% · Q3 16.1% · Q4 11.4% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
16.5%
4.1 pts worse
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 25.0% · Q3 19.2% · Q4 16.7% · 4Q avg 20.6% · 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 | 11.9% |
13.9%
2 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.3% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
11.7%
0.9 pts worse
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 22.2% · Q3 13.8% · Q4 12.1% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.8% |
0.9%
3.9 pts worse
|
1.0%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.3% · Q3 4.9% · Q4 3.9% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.7%
0.2 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 4.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
20.4%
4.4 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 9.2% · Q3 13.8% · Q4 20.3% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.6%
0.7 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 2.3% · Q3 6.7% · Q4 9.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.9% |
82.8%
22.9 pts worse
|
81.7%
21.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.0% · Q2 58.5% · Q3 59.1% · Q4 65.5% · 4Q avg 59.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
11.5%
4.5 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 18.8% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.4% |
79.5%
25.1 pts worse
|
79.7%
25.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
24.2%
7.2 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 35.4% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-20 · Fire 2024-09-20
34 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-08-02 · Fire 2023-08-02
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-10-22
F · Potential for more than minimal harm
2025-09-08
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 2025-10-22
F · Potential for more than minimal harm
2025-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-22
F · Potential for more than minimal harm
2025-09-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-22
F · Potential for more than minimal harm
2025-09-08
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 2025-10-22
F · Potential for more than minimal harm
2025-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-22
E · Potential for more than minimal harm
2025-09-08
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 2025-10-22
E · Potential for more than minimal harm
2025-09-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-22
F · Potential for more than minimal harm
2024-09-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-20
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-17
F · Potential for more than minimal harm
2023-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-08
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 2025-12-09
F · Potential for more than minimal harm
2025-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-09-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-09-08
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-09-08
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 2025-12-09
E · Potential for more than minimal harm
2025-09-08
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-09-08
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 2025-10-22
D · Potential for more than minimal harm
2025-09-08
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 2025-12-09
D · Potential for more than minimal harm
2025-09-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-08
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 2025-10-22
D · Potential for more than minimal harm
2025-09-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-09-08
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 2025-10-22
D · Potential for more than minimal harm
2025-09-08
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-09-08
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 2025-10-22
D · Potential for more than minimal harm
2025-08-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-29
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 2025-07-01
F · Potential for more than minimal harm
2025-02-12
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 2025-04-09
E · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-09
G · Actual harm
2024-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-17
G · Actual harm
2024-09-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-20
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 2024-10-17
F · Potential for more than minimal harm
2024-09-20
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 2024-10-17
F · Potential for more than minimal harm
2024-09-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-20
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 2024-11-20
E · Potential for more than minimal harm
2024-09-20
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 2024-11-20
E · Potential for more than minimal harm
2024-09-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-17
D · Potential for more than minimal harm
2024-09-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-20
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 2024-10-17
D · Potential for more than minimal harm
2024-09-20
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 2024-11-20
D · Potential for more than minimal harm
2024-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-20
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 2024-10-17
D · Potential for more than minimal harm
2024-09-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-20
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-20
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-05-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-24
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 2024-06-25
D · Potential for more than minimal harm
2024-05-24
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-24
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-24
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-24
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-03-14
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 2024-04-19
D · Potential for more than minimal harm
2024-03-14
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 2024-04-19
D · Potential for more than minimal harm
2024-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-19
J · Immediate jeopardy
2023-10-11
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 2023-10-30
F · Potential for more than minimal harm
2023-10-11
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-10-11
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 2023-10-30
D · Potential for more than minimal harm
2023-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-23
F · Potential for more than minimal harm
2023-08-02
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 2023-09-05
D · Potential for more than minimal harm
2023-08-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-02
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 2023-09-05
D · Potential for more than minimal harm
2023-08-02
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 2023-09-05
D · Potential for more than minimal harm
2023-08-02
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 2023-09-05
D · Potential for more than minimal harm
2023-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-04-05
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 2023-05-01
D · Potential for more than minimal harm
2023-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-01
Penalties and ownership
What sits behind the stars
$52,007
2024-08-30
Fine
Fine · fine $52,007
Fine
$0
2024-08-30
Payment Denial
Payment Denial · denial start 2024-10-18 · 33 days
33 day denial
$53,853
2023-10-11
Fine
Fine · fine $53,853
Fine
$0
2023-10-11
Payment Denial
Payment Denial · denial start 2023-11-01 · 22 days
22 day denial
Ownership
Atrium Centers, Inc.
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Operational/Managerial Control · Individual
Amicus Capital Holdings Inc Esop
5% Or Greater Indirect Ownership Interest · Organization
Amicus Capital Holdings Inc Esop
Operational/Managerial Control · Organization
Anderson, Curt
Operational/Managerial Control · Individual
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Atrium Centers, Inc.
Operational/Managerial Control · Organization
Bailey, Essel
5% Or Greater Indirect Ownership Interest · Individual
Bailey, Essel
Corporate Director · Individual
Browne, Erika
Operational/Managerial Control · Individual
Cherry, Jill
Operational/Managerial Control · Individual
Finney, Donald
5% Or Greater Indirect Ownership Interest · Individual
Finney, Donald
Corporate Director · Individual
Gardner, Leslie
Operational/Managerial Control · Individual
Hendershot, Neil
Operational/Managerial Control · Individual
Israel, Robert
Operational/Managerial Control · Individual
Johnson, Cindy
Operational/Managerial Control · Individual
La Rocco, Chrissie
Operational/Managerial Control · Individual
Lockhart, Dennis
Corporate Director · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Paredes, Miguel
5% Or Greater Indirect Ownership Interest · Individual
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