Vandalia, OH

Momentous Health At Vandalia

2-star overall rating with 1-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

208 North Cassel Road, Vandalia, OH

(937) 898-4202

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

118

Certified beds

Average residents

99

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1995-11-10

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.25

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

1.70

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

2.99

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.30

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.67

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.12

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.20

CMS adjusted RN staffing hours

Adjusted total hours

2.44

CMS adjusted total nurse staffing hours

Case-mix index

1.68

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

57%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,103

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

Performance score

27.80

Composite VBP score used to determine payment impact.

Payment multiplier

0.9847

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

4.55

Baseline 33.77% · Performance 45.10% · Measure score 4.55 · Achievement 4.55 · Improvement 0

Adjusted total nurse staffing

1.01

Baseline 2.59 hours · Performance 3.07 hours · Measure score 1.01 · Achievement 0 · Improvement 1.01

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.3%
10.72%
0.6 pts worse
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 6.83%
Discharge to community Not Available
50.57%
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary 1.01
1.02
About the same
Drug regimen review with follow-up Not Available
95.27%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Falls with major injury Not Available
0.77%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened Not Available
2.29%
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 111
Staff flu vaccination coverage 2.46%
42%
39.5 pts worse
Numerator 3 · Denominator 122
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 84.2%
92.4%
8.2 pts worse
93.4%
9.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 83.8% · Q2 90.5% · Q3 82.5% · Q4 80.0% · 4Q avg 84.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 90.9%
94.5%
3.6 pts worse
95.5%
4.6 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9%
Percentage of long-stay residents experiencing one or more falls with major injury 2.8%
3.3%
0.5 pts better
3.3%
0.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 5.2% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 91.0%
26.1%
64.9 pts worse
11.4%
79.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 92.9% · Q3 98.9% · Q4 97.8% · 4Q avg 91.0%
Percentage of long-stay residents who lose too much weight 4.6%
6.2%
1.6 pts better
5.4%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.8% · Q3 2.3% · Q4 4.7% · 4Q avg 4.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 32.8%
25.4%
7.4 pts worse
19.6%
13.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 33.0% · Q3 30.2% · Q4 33.3% · 4Q avg 32.8%
Percentage of long-stay residents who received an antipsychotic medication 20.5%
11.5%
9 pts worse
16.7%
3.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 10.0% · Q3 20.5% · Q4 28.9% · 4Q avg 20.5% · 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 4.9%
7.7%
2.8 pts better
16.3%
11.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 9.3% · Q3 5.7% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 3.8%
6.2%
2.4 pts better
14.9%
11.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.7% · Q3 2.3% · Q4 1.1% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.2%
0.2 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.0%
0.5%
0.5 pts better
1.7%
1.7 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 new or worsened bowel or bladder incontinence 17.9%
21.7%
3.8 pts better
19.8%
1.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.5% · Q3 17.5% · Q4 13.1% · 4Q avg 17.9%
Percentage of long-stay residents with pressure ulcers 2.9%
3.7%
0.8 pts better
5.1%
2.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.1% · Q3 2.8% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 43.5%
78.1%
34.6 pts worse
81.7%
38.2 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 44.1% · Q3 48.1% · Q4 40.9% · 4Q avg 43.5%
Percentage of short-stay residents who had an outpatient emergency department visit 16.7%
12.5%
4.2 pts worse
12.0%
4.7 pts worse
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 20.0% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.2%
1.2 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 50.0%
75.6%
25.6 pts worse
79.7%
29.7 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 25.8%
25.1%
0.7 pts worse
23.9%
1.9 pts worse
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 30.0% · Expected 27.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-04-24 · Fire 2023-04-24

21 health deficiencies

Top issue: Resident Rights (4 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2019-11-07 · Fire 2019-11-07

15 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

26 fire-safety deficiencies

Top issue: Smoke (10 deficiencies)

Cycle 3 Health 2018-10-04 · Fire 2018-10-04

9 health deficiencies

Top issue: Resident Rights (4 deficiencies)

16 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-08

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2024-11-14

F · Potential for more than minimal harm 2024-10-08

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 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-10-08

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 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-10-08

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 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-10-08

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 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-10-08

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-11-14

F · Potential for more than minimal harm 2023-04-24

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-06-20

F · Potential for more than minimal harm 2023-04-24

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 2023-06-20

F · Potential for more than minimal harm 2023-04-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-20

F · Potential for more than minimal harm 2023-04-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-06-20

F · Potential for more than minimal harm 2023-04-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-06-20

F · Potential for more than minimal harm 2023-04-24

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2023-06-20

F · Potential for more than minimal harm 2023-04-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-06-20

E · Potential for more than minimal harm 2023-04-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-06-20

F · Potential for more than minimal harm 2019-11-07

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2019-12-13

F · Potential for more than minimal harm 2019-11-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-12-13

E · Potential for more than minimal harm 2019-11-07

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2019-12-13

E · Potential for more than minimal harm 2019-11-07

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 2019-12-13

E · Potential for more than minimal harm 2019-11-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-12-13

E · Potential for more than minimal harm 2019-11-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-12-13

E · Potential for more than minimal harm 2019-11-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-12-13

F · Potential for more than minimal harm 2018-10-04

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

E23 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for medical documentation.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

E33 · Emergency Preparedness Deficiencies

Fire Safety

Establish methods for sharing information.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

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 2018-10-31

F · Potential for more than minimal harm 2018-10-04

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2018-10-31

F · Potential for more than minimal harm 2018-10-04

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2018-10-31

E · Potential for more than minimal harm 2018-10-04

K226 · Egress Deficiencies

Fire Safety

Have horizontal exits used in accordance with safety requirements.

Corrected 2018-10-31

E · Potential for more than minimal harm 2018-10-04

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 2018-10-31

E · Potential for more than minimal harm 2018-10-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2018-10-31

E · Potential for more than minimal harm 2018-10-04

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2018-10-31

E · Potential for more than minimal harm 2018-10-04

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2018-10-31

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-12-04

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 2024-12-18

E · Potential for more than minimal harm 2024-10-08

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 2024-11-14

E · Potential for more than minimal harm 2024-10-08

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 2024-11-14

D · Potential for more than minimal harm 2024-10-08

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 2024-11-14

F · Potential for more than minimal harm 2024-09-04

F837 · Administration Deficiencies

Health

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected 2024-07-22

E · Potential for more than minimal harm 2024-05-22

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 2024-06-10

D · Potential for more than minimal harm 2024-05-22

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 2024-04-18

F · Potential for more than minimal harm 2024-03-14

F839 · Administration Deficiencies

Health

Employ staff that are licensed, certified, or registered in accordance with state laws.

Corrected 2024-04-02

D · Potential for more than minimal harm 2023-07-18

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-07-28

F · Potential for more than minimal harm 2023-04-24

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-06-20

F · Potential for more than minimal harm 2023-04-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-20

E · Potential for more than minimal harm 2023-04-24

F569 · Resident Rights Deficiencies

Health

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Corrected 2023-06-20

E · Potential for more than minimal harm 2023-04-24

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 2023-06-20

E · Potential for more than minimal harm 2023-04-24

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 2023-06-20

E · Potential for more than minimal harm 2023-04-24

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 2023-06-20

E · Potential for more than minimal harm 2023-04-24

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 2023-06-20

E · Potential for more than minimal harm 2023-04-24

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 2023-06-20

E · Potential for more than minimal harm 2023-04-24

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

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 2023-06-20

D · Potential for more than minimal harm 2023-04-24

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 2023-06-20

D · Potential for more than minimal harm 2023-04-24

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

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 2023-06-20

D · Potential for more than minimal harm 2023-04-24

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 2023-06-20

D · Potential for more than minimal harm 2023-04-24

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

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 2023-06-20

D · Potential for more than minimal harm 2023-04-24

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-06-20

D · Potential for more than minimal harm 2023-04-24

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 2023-06-20

D · Potential for more than minimal harm 2023-03-06

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 2023-03-24

D · Potential for more than minimal harm 2023-03-06

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-24

F · Potential for more than minimal harm 2019-11-07

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 2019-12-13

E · Potential for more than minimal harm 2019-11-07

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 2019-12-13

E · Potential for more than minimal harm 2019-11-07

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 2019-12-13

E · Potential for more than minimal harm 2019-11-07

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 2019-12-13

D · Potential for more than minimal harm 2019-11-07

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 2019-12-13

D · Potential for more than minimal harm 2019-11-07

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 2019-12-13

D · Potential for more than minimal harm 2019-11-07

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 2019-12-13

E · Potential for more than minimal harm 2018-10-04

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2018-10-31

E · Potential for more than minimal harm 2018-10-04

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 2018-10-31

E · Potential for more than minimal harm 2018-10-04

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-10-31

D · Potential for more than minimal harm 2018-10-04

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2018-10-31

D · Potential for more than minimal harm 2018-10-04

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 2018-10-31

D · Potential for more than minimal harm 2018-10-04

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2018-10-31

Penalties and ownership

What sits behind the stars

$0 2023-04-24

Payment Denial

Payment Denial · denial start 2023-06-03 · 17 days

17 day denial

Ownership

Stein, Mark

5% Or Greater Direct Ownership Interest · Individual

50% 4 facilities 2022-05-01
Tenenbaum, Michael

5% Or Greater Direct Ownership Interest · Individual

50% 4 facilities 2022-05-01
Ferguson, Harold

Operational/Managerial Control · Individual

0% 3 facilities 2024-10-01
Stein, Mark

Corporate Officer · Individual

0% 4 facilities 2022-05-01
Tenenbaum, Michael

Corporate Officer · Individual

0% 4 facilities 2022-05-01
Walter, Mandy

Operational/Managerial Control · Individual

0% 2 facilities 2024-10-15

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