Montrose, MI

Medilodge of Montrose Inc

2-star overall rating with 1-star inspections with abuse icon flag with $135,954 in total fines with 37 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

9317 West Vienna Road, Montrose, MI

(810) 639-6171

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

121

Certified beds

Average residents

108

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Medilodge

Operator or chain grouping

Approved since

2002-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

50 facilities

Chain averages 3 overall / 3 health / 4 staffing / 4 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

0.66

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.98

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.38

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.03

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.64

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.49

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.42

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

4.12

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

55%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

61%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,720

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

Performance score

10.87

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 23.40% · Performance 23.94% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 7.82% · Performance 8.45% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.82

Baseline 64.76% · Performance 56.25% · Measure score 1.82 · Achievement 1.82 · Improvement 1.63

Adjusted total nurse staffing

2.53

Baseline 3.89 hours · Performance 3.80 hours · Measure score 2.53 · Achievement 2.53 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.98%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 161 · Observed rate 11.18% · Lower 95% interval 7.75%
Discharge to community	56.17%	50.57% 5.6 pts better	No Different than the National Rate · Eligible stays 147 · Observed rate 48.3% · Lower 95% interval 49.15%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 113 · Denominator 113
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 113
Discharge self-care score	53.95%	53.69% 0.3 pts better	Numerator 41 · Denominator 76
Discharge mobility score	57.89%	50.94% 7 pts better	Numerator 44 · Denominator 76
Pressure ulcers or injuries, new or worsened	0.88%	2.29% 1.4 pts better	Numerator 1 · Denominator 113 · Adjusted rate 0.84%
Healthcare-associated infections requiring hospitalization	8.45%	7.12% 1.3 pts worse	No Different than the National Rate · Eligible stays 97 · Observed rate 10.31% · Lower 95% interval 5.46%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 152
Staff flu vaccination coverage	2.54%	42% 39.5 pts worse	Numerator 3 · Denominator 118
Discharge function score	64.47%	56.45% 8 pts better	Numerator 49 · Denominator 76
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 32 · Denominator 32
Transfer of health information to patient	98.39%	96.28% 2.1 pts better	Numerator 61 · Denominator 62
Resident COVID-19 vaccinations up to date	15.79%	25.2% 9.4 pts worse	Numerator 9 · Denominator 57

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.7 0.2 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.5 0.3 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	91.3%	95.0% 3.7 pts worse	93.4% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 96.5% · Q3 90.6% · Q4 85.5% · 4Q avg 91.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 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	4.4%	3.1% 1.3 pts worse	3.3% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 7.1% · Q4 7.2% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.3%	4.1% 3.8 pts better	11.4% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3%
Percentage of long-stay residents who lose too much weight	9.6%	5.5% 4.1 pts worse	5.4% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 10.4% · Q3 6.6% · Q4 13.2% · 4Q avg 9.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.7%	19.6% 4.1 pts worse	19.6% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 23.1% · Q3 23.4% · Q4 20.8% · 4Q avg 23.7%
Percentage of long-stay residents who received an antipsychotic medication	15.5%	16.5% 1 pts better	16.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 14.3% · Q3 15.3% · Q4 17.5% · 4Q avg 15.5% · 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	5.7%	13.9% 8.2 pts better	16.3% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 6.1% · Q4 11.4% · 4Q avg 5.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.5%	11.7% 5.2 pts better	14.9% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.5% · Q3 7.2% · Q4 9.7% · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 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	2.7%	1.7% 1 pts worse	1.7% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 3.6% · Q4 4.9% · 4Q avg 2.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.6%	20.4% 5.2 pts worse	19.8% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 25.2% · Q3 27.8% · Q4 22.7% · 4Q avg 25.6%
Percentage of long-stay residents with pressure ulcers	4.6%	5.6% 1 pts better	5.1% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.6% · Q3 3.8% · Q4 3.2% · 4Q avg 4.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	53.3%	82.8% 29.5 pts worse	81.7% 28.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 69.1% · Q3 46.5% · Q4 21.6% · 4Q avg 53.3%
Percentage of short-stay residents who had an outpatient emergency department visit	6.3%	11.5% 5.2 pts better	12.0% 5.7 pts better	Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.7% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.3% 1 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	73.1%	79.5% 6.4 pts worse	79.7% 6.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 73.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.7%	24.2% 8.5 pts worse	23.9% 8.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 33.7% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-05 · Fire 2024-12-05

37 health deficiencies

Top issue: Quality of Life and Care (16 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-11-09 · Fire 2023-11-09

29 health deficiencies

Top issue: Quality of Life and Care (12 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-08-11 · Fire 2022-08-11

17 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-07

F · Potential for more than minimal harm 2024-12-05

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-01-07

E · Potential for more than minimal harm 2024-12-05

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 2025-01-07

F · Potential for more than minimal harm 2023-11-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-12-08

F · Potential for more than minimal harm 2023-11-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-09

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 2023-12-08

E · Potential for more than minimal harm 2023-11-09

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-09

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-12-08

F · Potential for more than minimal harm 2022-08-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-08-29

F · Potential for more than minimal harm 2022-08-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-08-29

E · Potential for more than minimal harm 2022-08-11

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 2022-08-29

E · Potential for more than minimal harm 2022-08-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-08-29

E · Potential for more than minimal harm 2022-08-11

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2022-08-29

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-12

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.

Not marked corrected

D · Potential for more than minimal harm 2025-11-21

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 2025-12-16

D · Potential for more than minimal harm 2025-11-21

F627 · Resident Rights Deficiencies

Health

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Corrected 2025-12-16

D · Potential for more than minimal harm 2025-11-21

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 2025-12-16

G · Actual harm 2025-08-14

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-08-14

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 2025-08-15

D · Potential for more than minimal harm 2025-08-01

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 2025-08-14

D · Potential for more than minimal harm 2025-08-01

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-14

D · Potential for more than minimal harm 2025-08-01

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-08-14

G · Actual harm 2025-07-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-08-07

E · Potential for more than minimal harm 2025-07-09

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 2025-08-07

E · Potential for more than minimal harm 2025-07-09

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 2025-08-07

E · Potential for more than minimal harm 2025-07-09

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 2025-08-07

E · Potential for more than minimal harm 2025-07-09

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-08-07

D · Potential for more than minimal harm 2025-07-09

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 2025-08-07

E · Potential for more than minimal harm 2025-06-11

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-06-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-06-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-04-08

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-04-16

D · Potential for more than minimal harm 2025-04-08

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 2025-03-24

C · Minimal harm 2025-04-08

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-04-16

E · Potential for more than minimal harm 2025-02-27

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 2025-03-19

E · Potential for more than minimal harm 2025-02-27

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-03-19

D · Potential for more than minimal harm 2025-02-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-19

E · Potential for more than minimal harm 2024-12-05

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 2025-01-07

E · Potential for more than minimal harm 2024-12-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-01-07

E · Potential for more than minimal harm 2024-12-05

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 2025-01-07

E · Potential for more than minimal harm 2024-12-05

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-01-07

E · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-01-07

D · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-01-07

D · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-01-07

D · Potential for more than minimal harm 2024-12-05

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 2025-01-07

D · Potential for more than minimal harm 2024-12-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-07

D · Potential for more than minimal harm 2024-12-05

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-01-07

D · Potential for more than minimal harm 2024-09-26

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 2024-10-15

D · Potential for more than minimal harm 2024-09-26

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-15

K · Immediate jeopardy 2024-07-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-01

D · Potential for more than minimal harm 2024-07-29

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-01

D · Potential for more than minimal harm 2024-07-29

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 2024-08-01

G · Actual harm 2024-07-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-07-03

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 2024-07-12

D · Potential for more than minimal harm 2024-07-03

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-07-03

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-07-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-01-29

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 2024-01-31

G · Actual harm 2023-11-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-12-08

G · Actual harm 2023-11-09

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 2023-12-08

F · Potential for more than minimal harm 2023-11-09

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 2023-12-08

F · Potential for more than minimal harm 2023-11-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-09

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 2023-12-08

E · Potential for more than minimal harm 2023-11-09

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-09

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-09

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-09

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 2023-12-08

D · Potential for more than minimal harm 2023-11-09

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-09

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-09

F693 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-09

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 2023-12-08

D · Potential for more than minimal harm 2023-11-09

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-09

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-12-20

G · Actual harm 2022-08-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-08-29

F · Potential for more than minimal harm 2022-08-11

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 2022-08-29

E · Potential for more than minimal harm 2022-08-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-08-29

E · Potential for more than minimal harm 2022-08-11

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 2022-08-29

E · Potential for more than minimal harm 2022-08-11

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2022-08-29