Cycle 1
Health 2025-06-09 · Fire 2025-06-09
41 health deficiencies
Top issue: Resident Rights (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Atlanta, GA
Nurse Care Of Buckhead
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $14,842 in total fines with 41 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2920 Pharr Court South Nw, Atlanta, GA
(404) 261-9043
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
220
Certified beds
Average residents
212
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wellington Health Care Services
Operator or chain grouping
Approved since
1971-12-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 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
0.24
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.88
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.74
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.44
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,453
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.43% · Performance 24.09% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.68
Baseline 11.23% · Performance 10.49% · Measure score 0.68 · Achievement 0 · Improvement 0.68
Total nurse turnover
1.04
Baseline 67.65% · Performance 61.05% · Measure score 1.04 · Achievement 0.64 · Improvement 1.04
Adjusted total nurse staffing
0.30
Baseline 2.75 hours · Performance 3 hours · Measure score 0.30 · Achievement 0 · Improvement 0.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.33% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 17.58% · Lower 95% interval 8.16% |
| Discharge to community | 36.87% |
50.57%
13.7 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 22.5% · Lower 95% interval 26.51% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 86.49% |
95.27%
8.8 pts worse
|
Numerator 160 · Denominator 185 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 185 |
| Discharge self-care score | 23.16% |
53.69%
30.5 pts worse
|
Numerator 22 · Denominator 95 |
| Discharge mobility score | 24.21% |
50.94%
26.7 pts worse
|
Numerator 23 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 2.72% |
2.29%
0.4 pts worse
|
Numerator 5 · Denominator 184 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | 10.49% |
7.12%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 20.51% · Lower 95% interval 6.55% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 23.16% |
56.45%
33.3 pts worse
|
Numerator 22 · Denominator 95 |
| Transfer of health information to provider | 81.25% |
95.95%
14.7 pts worse
|
Numerator 65 · Denominator 80 |
| Transfer of health information to patient | 70% |
96.28%
26.3 pts worse
|
Numerator 14 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 10 · Denominator 110 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 45.9% |
91.2%
45.3 pts worse
|
93.4%
47.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.0% · Q2 47.6% · Q3 41.3% · Q4 40.9% · 4Q avg 45.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 41.2% |
95.0%
53.8 pts worse
|
95.5%
54.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 41.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.6% · Q3 1.5% · Q4 2.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
9.6%
7.6 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 5.7% · Q3 0.0% · Q4 1.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
5.9%
5.3 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 9.2% · Q3 11.8% · Q4 10.5% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
20.7%
14.8 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 4.9% · Q3 3.7% · Q4 7.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
21.4%
3.6 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 30.3% · Q3 24.2% · Q4 21.1% · 4Q avg 25.0% · 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 | 15.0% |
17.9%
2.9 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 15.2% · Q3 16.7% · Q4 12.7% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
16.2%
0.6 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 15.7% · Q3 18.1% · Q4 14.4% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.1%
0.7 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.5%
2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 1.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
16.1%
8.3 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 25.5% · Q3 19.3% · Q4 25.4% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
6.2%
0.9 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.6% · Q3 9.5% · Q4 6.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 8.7% |
80.4%
71.7 pts worse
|
81.7%
73 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.9% · Q3 2.6% · Q4 5.1% · 4Q avg 8.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
12.2%
2.1 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 17.9% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.9% |
2.2%
4.7 pts worse
|
1.6%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 10.2% · Q3 6.1% · Q4 7.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 13.0% |
78.2%
65.2 pts worse
|
79.7%
66.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 13.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
24.2%
8.8 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 40.7% · Expected 29.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
36 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-30 · Fire 2021-12-30
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-09
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-06-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-25
F · Potential for more than minimal harm
2023-09-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-10-22
F · Potential for more than minimal harm
2023-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-22
F · Potential for more than minimal harm
2023-09-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-12-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-12-11
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 2026-02-11
D · Potential for more than minimal harm
2025-12-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-12-11
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 2026-02-11
D · Potential for more than minimal harm
2025-12-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-11
J · Immediate jeopardy
2025-06-09
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 2025-08-05
J · Immediate jeopardy
2025-06-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-05
J · Immediate jeopardy
2025-06-09
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-08-06
G · Actual harm
2025-06-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-06-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-06-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-06-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-06-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
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 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
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 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-05
C · Minimal harm
2025-06-09
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-03-04
F579 · Resident Rights Deficiencies
Health
Provide information about how to apply for and use Medicare and Medicaid benefits.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-04
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-04
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-04-18
B · Minimal harm
2025-03-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-08-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-08-01
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 2024-09-15
F · Potential for more than minimal harm
2024-08-01
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-08-01
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-08-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-08-01
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-08-01
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 2024-09-15
E · Potential for more than minimal harm
2024-08-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-08-01
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 2024-09-15
E · Potential for more than minimal harm
2024-08-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-08-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
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 2024-09-15
D · Potential for more than minimal harm
2024-08-01
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 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
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 2024-09-15
E · Potential for more than minimal harm
2023-09-07
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-22
E · Potential for more than minimal harm
2023-09-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-22
E · Potential for more than minimal harm
2023-09-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-07
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 2023-10-22
D · Potential for more than minimal harm
2023-09-07
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 2023-10-22
D · Potential for more than minimal harm
2023-09-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-07
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 2023-10-22
D · Potential for more than minimal harm
2023-09-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-07
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 2023-10-22
D · Potential for more than minimal harm
2023-09-07
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 2023-10-22
D · Potential for more than minimal harm
2023-09-07
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-09-07
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 2023-10-22
D · Potential for more than minimal harm
2023-09-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-22
F · Potential for more than minimal harm
2021-12-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-08
F · Potential for more than minimal harm
2021-12-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-02-08
D · Potential for more than minimal harm
2021-12-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-02-08
Penalties and ownership
What sits behind the stars
$5,346
2024-08-01
Fine
Fine · fine $5,346
Fine
$0
2024-08-01
Payment Denial
Payment Denial · denial start 2024-09-19 · 43 days
43 day denial
$2,659
2024-02-20
Fine
Fine · fine $2,659
Fine
$2,279
2024-02-12
Fine
Fine · fine $2,279
Fine
$4,558
2024-01-22
Fine
Fine · fine $4,558
Fine
Ownership
Wellington Healthcare Services LP
5% Or Greater Direct Ownership Interest · Organization
Andrews, James
5% Or Greater Indirect Ownership Interest · Individual
Andrews, James
Operational/Managerial Control · Individual
Andrews, James
Corporate Director · Individual
Andrews, James
Corporate Officer · Individual
Andwell Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Teresa
W-2 Managing Employee · Individual
Elkins Road Associates LLC
General Partnership Interest · Organization
Kelman, Moshe
Corporate Officer · Individual
Wellington Healthcare Services LP
Limited Partnership Interest · Organization
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