Cycle 1
Health 2025-02-20 · Fire 2025-02-20
16 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cincinnati, OH
Mt Airy Gardens Rehabilitation And Nursing Center
1-star overall rating with 1-star inspections with $10,039 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2250 Banning Road, Cincinnati, OH
(513) 591-0400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-04-09
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
0.44
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.86
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,624
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
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
0
Performance 63.77% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.55
Baseline 3.25 hours · Performance 3.23 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 2.08% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 48 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 16 · Denominator 32 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 18 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| 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 | 66.98% |
8.2%
58.8 pts better
|
Numerator 71 · Denominator 106 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 53.13% |
56.45%
3.3 pts worse
|
Numerator 17 · Denominator 32 |
| 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 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 1 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 44.8% |
92.4%
47.6 pts worse
|
93.4%
48.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.4% · Q2 49.3% · Q3 41.7% · Q4 39.0% · 4Q avg 44.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.6% |
94.5%
16.9 pts worse
|
95.5%
17.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 2.8% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 65.3% |
26.1%
39.2 pts worse
|
11.4%
53.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.6% · Q2 55.6% · Q3 72.1% · Q4 78.9% · 4Q avg 65.3% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
6.2%
4.8 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.0% · Q3 1.5% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
25.4%
10.4 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 11.9% · Q3 18.2% · Q4 18.2% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
11.5%
0.8 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.9% · Q3 8.2% · Q4 11.1% · 4Q avg 10.7% · 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 | 2.4% |
7.7%
5.3 pts better
|
16.3%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 2.9% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.6% |
6.2%
3.6 pts better
|
14.9%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.5% · Q3 3.1% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 25.3% |
21.7%
3.6 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 24.9% · Q3 20.7% · Q4 20.7% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
3.7%
3.6 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.7% · Q3 5.8% · Q4 5.1% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 9.3% |
78.1%
68.8 pts worse
|
81.7%
72.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 1.9% · Q3 12.3% · Q4 12.3% · 4Q avg 9.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
12.5%
4.3 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 9.5% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.2%
2.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 14.8% |
75.6%
60.8 pts worse
|
79.7%
64.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 14.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
25.1%
7.6 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 38.1% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-11 · Fire 2021-05-11
25 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
25 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2019-03-07 · Fire 2019-03-07
35 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-20
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-10
F · Potential for more than minimal harm
2024-08-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-08-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-15
E · Potential for more than minimal harm
2024-08-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-06-11
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-06-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-06-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-14
C · Minimal harm
2024-06-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-14
C · Minimal harm
2024-06-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-14
C · Minimal harm
2024-06-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-14
C · Minimal harm
2024-06-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-14
F · Potential for more than minimal harm
2021-05-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
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 2021-06-08
E · Potential for more than minimal harm
2021-05-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
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 2021-06-08
E · Potential for more than minimal harm
2021-05-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-08
C · Minimal harm
2021-05-11
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2021-06-08
F · Potential for more than minimal harm
2019-03-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-04-05
F · Potential for more than minimal harm
2019-03-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-04-05
F · Potential for more than minimal harm
2019-03-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-04-05
F · Potential for more than minimal harm
2019-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-04-05
F · Potential for more than minimal harm
2019-03-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-04-05
F · Potential for more than minimal harm
2019-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-03-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-03-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-04-05
Inspection history
Recent health citations
E · 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 2025-09-17
E · Potential for more than minimal harm
2025-09-08
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-09-17
F · Potential for more than minimal harm
2025-02-20
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 2025-03-10
F · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-20
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
D · Potential for more than minimal harm
2025-02-20
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-03-10
E · Potential for more than minimal harm
2024-08-13
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 2024-08-15
D · Potential for more than minimal harm
2024-06-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-14
J · Immediate jeopardy
2024-05-20
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 2024-06-14
E · Potential for more than minimal harm
2024-05-20
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 2024-06-14
D · Potential for more than minimal harm
2024-05-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-14
B · Minimal harm
2024-05-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-02-12
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 2024-02-23
E · Potential for more than minimal harm
2023-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-20
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 2023-12-01
D · Potential for more than minimal harm
2023-11-20
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-06-07
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 2023-06-15
D · Potential for more than minimal harm
2023-06-07
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 2023-06-15
D · Potential for more than minimal harm
2023-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-06-07
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 2023-06-15
D · Potential for more than minimal harm
2023-06-07
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 2023-06-15
D · Potential for more than minimal harm
2023-06-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-04-28
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 2023-05-06
F · Potential for more than minimal harm
2023-03-03
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 2023-03-20
F · Potential for more than minimal harm
2021-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-06-08
E · Potential for more than minimal harm
2021-05-11
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 2021-06-08
E · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-11
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 2021-06-08
D · Potential for more than minimal harm
2021-05-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-06-08
F · Potential for more than minimal harm
2019-03-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-03-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
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 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-04-05
C · Minimal harm
2019-03-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-04-05
Penalties and ownership
What sits behind the stars
$10,039
2024-05-20
Fine
Fine · fine $10,039
Fine
Ownership
Airy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Airy Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Shapiro, Naftali
5% Or Greater Indirect Ownership Interest · Individual
Airy Management
Operational/Managerial Control · Organization
Owens, Karrie
W-2 Managing Employee · Individual
Rivera, Emmanuel
Contracted Managing Employee · Individual
Shapiro, Naftali
Corporate Director · Individual
Shapiro, Naftali
W-2 Managing Employee · Individual
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