Cycle 1
Health 2024-10-22 · Fire 2024-10-22
22 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Munster, IN
Munster Med-Inn
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
7935 Calumet Ave, Munster, IN
(219) 836-8300
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
225
Certified beds
Average residents
155
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Casa Consulting
Operator or chain grouping
Approved since
1972-09-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 1 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
12,157
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.78
Baseline 23.97% · Performance 22.39% · Measure score 1.78 · Achievement 0 · Improvement 1.78
Healthcare-associated infections
0
Baseline 9.72% · Performance 10.57% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.69
Baseline 51.35% · Performance 48.61% · Measure score 3.69 · Achievement 3.69 · Improvement 0.53
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 12.34% · Lower 95% interval 7.45% |
| Discharge to community | 43.46% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 31.69% · Lower 95% interval 36.27% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 95.77% |
95.27%
0.5 pts better
|
Numerator 136 · Denominator 142 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 142 |
| Discharge self-care score | 50.63% |
53.69%
3.1 pts worse
|
Numerator 40 · Denominator 79 |
| Discharge mobility score | 54.43% |
50.94%
3.5 pts better
|
Numerator 43 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 5.63% |
2.29%
3.3 pts worse
|
Numerator 8 · Denominator 142 · Adjusted rate 3.57% |
| Healthcare-associated infections requiring hospitalization | 10.57% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 121 · Observed rate 18.18% · Lower 95% interval 7.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 175 |
| Staff flu vaccination coverage | 6.19% |
42%
35.8 pts worse
|
Numerator 19 · Denominator 307 |
| Discharge function score | 54.43% |
56.45%
2 pts worse
|
Numerator 43 · Denominator 79 |
| Transfer of health information to provider | 98.33% |
95.95%
2.4 pts better
|
Numerator 59 · Denominator 60 |
| Transfer of health information to patient | 94.29% |
96.28%
2 pts worse
|
Numerator 33 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 12% |
25.2%
13.2 pts worse
|
Numerator 9 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.8% |
93.6%
19.8 pts worse
|
93.4%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.9% · Q2 74.4% · Q3 75.9% · Q4 77.8% · 4Q avg 73.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.9% |
95.4%
19.5 pts worse
|
95.5%
19.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.8%
1.4 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.3% · Q3 2.2% · Q4 1.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.8% |
24.6%
2.8 pts better
|
11.4%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 20.2% · Q3 26.9% · Q4 23.5% · 4Q avg 21.8% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.6%
0.5 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.2% · Q3 9.2% · Q4 6.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
23.5%
10.3 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.2% · Q3 10.5% · Q4 14.5% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
14.8%
3.3 pts worse
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 17.7% · Q3 18.0% · Q4 20.6% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.0% |
13.3%
9.3 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 0.0% · Q3 1.9% · Q4 5.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
11.7%
8.2 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 0.9% · Q3 2.4% · Q4 3.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
24.2%
1.7 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 22.4% · Q3 24.5% · Q4 26.7% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.1%
0.7 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.3% · Q3 4.9% · Q4 4.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.7% |
81.6%
17.9 pts worse
|
81.7%
18 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.4% · Q2 65.5% · Q3 71.4% · Q4 75.0% · 4Q avg 63.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
10.5%
2.4 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.1% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.6% |
79.0%
6.4 pts worse
|
79.7%
7.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
22.4%
2.4 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 29.8% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-20 · Fire 2023-11-20
17 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-11-09 · Fire 2022-11-09
19 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-04
F · Potential for more than minimal harm
2023-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-11-20
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-20
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-20
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 2023-12-19
E · Potential for more than minimal harm
2023-11-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-19
E · Potential for more than minimal harm
2022-11-09
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-12-13
E · Potential for more than minimal harm
2022-11-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-13
E · Potential for more than minimal harm
2022-11-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-13
D · Potential for more than minimal harm
2022-11-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-13
D · Potential for more than minimal harm
2022-11-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-13
C · Minimal harm
2022-11-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-13
B · Minimal harm
2022-11-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-13
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-28
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.
Not marked corrected
J · Immediate jeopardy
2026-01-28
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-01-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2026-01-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Not marked corrected
D · Potential for more than minimal harm
2025-10-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-19
G · Actual harm
2024-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-13
G · Actual harm
2024-10-22
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 2024-12-13
F · Potential for more than minimal harm
2024-10-22
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 2024-12-13
E · Potential for more than minimal harm
2024-10-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-22
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 2024-11-08
E · Potential for more than minimal harm
2024-10-22
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-22
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 2024-12-13
D · Potential for more than minimal harm
2024-10-22
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 2024-11-08
D · Potential for more than minimal harm
2024-10-22
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 2024-11-08
D · Potential for more than minimal harm
2024-10-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-22
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 2024-11-08
D · Potential for more than minimal harm
2024-10-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-08
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 2024-07-17
D · Potential for more than minimal harm
2024-07-03
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 2024-07-17
D · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-07
F · Potential for more than minimal harm
2023-11-20
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 2023-12-04
E · Potential for more than minimal harm
2023-11-20
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 2023-12-04
E · Potential for more than minimal harm
2023-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-04
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 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
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 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
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 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-20
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 2023-12-04
E · Potential for more than minimal harm
2023-06-28
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 2023-07-07
D · Potential for more than minimal harm
2023-06-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-07
D · Potential for more than minimal harm
2022-11-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
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 2022-11-21
D · Potential for more than minimal harm
2022-11-09
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 2022-11-21
D · Potential for more than minimal harm
2022-11-09
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 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
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 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-11-09
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 2022-11-21
D · Potential for more than minimal harm
2022-11-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-21
Penalties and ownership
What sits behind the stars
$0
2024-10-22
Payment Denial
Payment Denial · denial start 2024-11-16 · 27 days
27 day denial
Ownership
Major Hospital
5% Or Greater Direct Ownership Interest · Organization
Horner, John
Corporate Officer · Individual
Seflers, Lee
Operational/Managerial Control · Individual
Seflers, Lee
Contracted Managing Employee · Individual
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