Mansfield, OH

Oak Grove Manor

1-star overall rating with 1-star inspections with $15,593 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1670 Crider Rd, Mansfield, OH

(419) 589-6222

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lionstone Care

Operator or chain grouping

Approved since

1991-05-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

22 facilities

Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.41

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.11

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.24

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.14

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.77

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.04

CMS adjusted total nurse staffing hours

Case-mix index

1.46

Higher values indicate more complex resident acuity

RN turnover

90%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

76%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,812

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

Performance score

19.03

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

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

5.23

Baseline 8.68% · Performance 6.57% · Measure score 5.23 · Achievement 4.24 · Improvement 5.23

Total nurse turnover

0.48

Baseline 81.36% · Performance 75.81% · Measure score 0.48 · Achievement 0 · Improvement 0.48

Adjusted total nurse staffing

Baseline 2.75 hours · Performance 2.82 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.51%	10.72% 1.2 pts better	No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 5.82%
Discharge to community	46.98%	50.57% 3.6 pts worse	No Different than the National Rate · Eligible stays 36 · Observed rate 36.11% · Lower 95% interval 31.45%
Medicare spending per beneficiary	1.16	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 61 · Denominator 61
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 61
Discharge self-care score	18.52%	53.69% 35.2 pts worse	Numerator 5 · Denominator 27
Discharge mobility score	51.85%	50.94% 0.9 pts better	Numerator 14 · Denominator 27
Pressure ulcers or injuries, new or worsened	3.28%	2.29% 1 pts worse	Numerator 2 · Denominator 61 · Adjusted rate 2.72%
Healthcare-associated infections requiring hospitalization	6.57%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.61%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 77
Staff flu vaccination coverage	2.44%	42% 39.6 pts worse	Numerator 4 · Denominator 164
Discharge function score	33.33%	56.45% 23.1 pts worse	Numerator 9 · Denominator 27
Transfer of health information to provider	67.65%	95.95% 28.3 pts worse	Numerator 23 · Denominator 34
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	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 29

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.8 0.7 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	1.8 0.1 pts worse	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	24.7%	92.4% 67.7 pts worse	93.4% 68.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.5% · Q3 25.0% · Q4 41.7% · 4Q avg 24.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	82.4%	94.5% 12.1 pts worse	95.5% 13.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 82.4%
Percentage of long-stay residents experiencing one or more falls with major injury	3.8%	3.3% 0.5 pts worse	3.3% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 6.7% · Q4 5.0% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	34.7%	26.1% 8.6 pts worse	11.4% 23.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 74.0% · Q2 34.2% · Q3 17.0% · Q4 16.4% · 4Q avg 34.7%
Percentage of long-stay residents who lose too much weight	9.0%	6.2% 2.8 pts worse	5.4% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 12.0% · Q3 9.1% · Q4 9.4% · 4Q avg 9.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.6%	25.4% 10.8 pts better	19.6% 5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 13.5% · Q3 15.8% · Q4 10.9% · 4Q avg 14.6%
Percentage of long-stay residents who received an antipsychotic medication	18.1%	11.5% 6.6 pts worse	16.7% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.5% · Q3 18.6% · Q4 18.8% · 4Q avg 18.1% · 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	8.7%	7.7% 1 pts worse	16.3% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q4 5.5% · 4Q avg 8.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.3%	6.2% 2.1 pts worse	14.9% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 10.9% · Q3 11.1% · Q4 5.8% · 4Q avg 8.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	0.5% 0.4 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.4%	21.7% 2.7 pts worse	19.8% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 21.4% · Q3 29.8% · Q4 21.8% · 4Q avg 24.4%
Percentage of long-stay residents with pressure ulcers	6.6%	3.7% 2.9 pts worse	5.1% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 14.0% · Q3 3.1% · Q4 1.3% · 4Q avg 6.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	17.8%	78.1% 60.3 pts worse	81.7% 63.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.5% · Q3 17.9% · Q4 38.0% · 4Q avg 17.8%
Percentage of short-stay residents who had an outpatient emergency department visit	13.3%	12.5% 0.8 pts worse	12.0% 1.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 13.5% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.4%	1.2% 1.2 pts worse	1.6% 0.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.2% · Q3 3.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	11.4%	75.6% 64.2 pts worse	79.7% 68.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 11.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.6%	25.1% 1.5 pts worse	23.9% 2.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 28.8% · Expected 25.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-01 · Fire 2025-07-01

13 health deficiencies

Top issue: Nursing and Physician Services (3 deficiencies)

3 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2024-05-16 · Fire 2024-05-16

20 health deficiencies

Top issue: Nutrition and Dietary (5 deficiencies)

11 fire-safety deficiencies

Top issue: Miscellaneous (3 deficiencies)

Cycle 3 Health 2022-11-15 · Fire 2022-11-15

38 health deficiencies

Top issue: Quality of Life and Care (13 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-01

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-25

F · Potential for more than minimal harm 2025-07-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-25

F · Potential for more than minimal harm 2025-07-01

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 2025-07-25

F · Potential for more than minimal harm 2024-05-16

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-06-07

E · Potential for more than minimal harm 2024-05-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-07

E · Potential for more than minimal harm 2024-05-16

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-06-07

F · Potential for more than minimal harm 2023-07-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-01

F · Potential for more than minimal harm 2023-07-31

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-09-01

F · Potential for more than minimal harm 2022-11-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-03-06

F · Potential for more than minimal harm 2022-11-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-06

F · Potential for more than minimal harm 2022-11-15

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2023-03-06

F · Potential for more than minimal harm 2022-11-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-06

F · Potential for more than minimal harm 2022-11-15

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-03-06

F · Potential for more than minimal harm 2022-11-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-06

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-25

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-11-17

D · Potential for more than minimal harm 2025-09-25

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-11-17

F · Potential for more than minimal harm 2025-07-01

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 2025-07-25

F · Potential for more than minimal harm 2025-07-01

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2025-07-25

E · Potential for more than minimal harm 2025-07-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-01

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 2025-07-25

D · Potential for more than minimal harm 2025-07-01

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-01

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-01

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 2025-07-25

C · Minimal harm 2025-07-01

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-07-25

C · Minimal harm 2025-07-01

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-07-25

B · Minimal harm 2025-07-01

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-07-25

D · Potential for more than minimal harm 2024-12-23

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 2024-12-27

D · Potential for more than minimal harm 2024-12-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-10-29

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 2024-11-22

F · Potential for more than minimal harm 2024-10-29

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-29

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-11-22

F · Potential for more than minimal harm 2024-07-31

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-08-22

D · Potential for more than minimal harm 2024-07-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-08-22

D · Potential for more than minimal harm 2024-07-31

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 2024-08-22

D · Potential for more than minimal harm 2024-07-31

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-05-16

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-06-07

E · Potential for more than minimal harm 2024-05-16

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-06-07

E · Potential for more than minimal harm 2024-05-16

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-06-07

E · Potential for more than minimal harm 2024-05-16

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-16

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

J · Immediate jeopardy 2024-02-06

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 2024-02-24

G · Actual harm 2024-02-06

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-24

F · Potential for more than minimal harm 2024-02-06

F868 · Administration Deficiencies

Health

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

Corrected 2024-02-24

F · Potential for more than minimal harm 2024-02-06

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 2024-02-24

E · Potential for more than minimal harm 2024-02-06

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 2024-02-24

D · Potential for more than minimal harm 2024-02-06

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 2024-02-24

D · Potential for more than minimal harm 2024-02-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-24

D · Potential for more than minimal harm 2023-12-27

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-24

D · Potential for more than minimal harm 2023-11-21

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 2023-12-01

D · Potential for more than minimal harm 2023-11-21

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

D · Potential for more than minimal harm 2023-09-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-08-01

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 2023-09-01

D · Potential for more than minimal harm 2023-08-01

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-01

F · Potential for more than minimal harm 2022-11-15

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 2023-03-07

F · Potential for more than minimal harm 2022-11-15

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 2023-03-07

F · Potential for more than minimal harm 2022-11-15

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 2023-03-07

F · Potential for more than minimal harm 2022-11-15

F868 · Administration Deficiencies

Health

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

Corrected 2023-03-07

F · Potential for more than minimal harm 2022-11-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-07

E · Potential for more than minimal harm 2022-11-15

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 2023-03-07

E · Potential for more than minimal harm 2022-11-15

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 2023-03-07

E · Potential for more than minimal harm 2022-11-15

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-03-07

E · Potential for more than minimal harm 2022-11-15

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 2023-03-07

E · Potential for more than minimal harm 2022-11-15