Oakland, IA

Oakland Manor

1-star overall rating with 1-star inspections with $15,593 in total fines with 31 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

737 North Highway, Oakland, IA

(712) 482-6403

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 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

Mgm Healthcare

Operator or chain grouping

Approved since

1994-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

30 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 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

0.74

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.57 · national 0.87

Aide hours / resident day

2.00

Nurse aide staffing · state 2.53 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.30 · national 1.54

Weekend hours

2.88

Weekend nurse staffing · state 3.35 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.68

CMS adjusted RN staffing hours

Adjusted total hours

3.20

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

88%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

67%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,409

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

Performance score

16.83

Composite VBP score used to determine payment impact.

Payment multiplier

0.9817

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

3.37

Baseline 75.44% · Performance 55.88% · Measure score 3.37 · Achievement 1.91 · Improvement 3.37

Adjusted total nurse staffing

Baseline 4.04 hours · Performance 2.59 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.89%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 41 · Observed rate 14.63% · Lower 95% interval 6.65%
Discharge to community	50.3%	50.57% 0.3 pts worse	No Different than the National Rate · Eligible stays 33 · Observed rate 45.45% · Lower 95% interval 36.97%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	70%	95.27% 25.3 pts worse	Numerator 14 · Denominator 20
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 20
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 20 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 5 · Denominator 5
Staff flu vaccination coverage	35.44%	42% 6.6 pts worse	Numerator 28 · Denominator 79
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	94.0% 3.3 pts better	93.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 100.0% · Q3 100.0% · Q4 97.7% · 4Q avg 97.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.1%	95.2% 0.9 pts better	95.5% 0.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1%
Percentage of long-stay residents experiencing one or more falls with major injury	2.2%	3.7% 1.5 pts better	3.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.3% · Q3 2.2% · Q4 2.3% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	12.6%	4.0% 8.6 pts worse	11.4% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 15.4% · Q3 5.0% · Q4 17.9% · 4Q avg 12.6%
Percentage of long-stay residents who lose too much weight	2.5%	4.9% 2.4 pts better	5.4% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.3%	20.6% 5.3 pts better	19.6% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 16.3% · Q3 18.2% · Q4 15.4% · 4Q avg 15.3%
Percentage of long-stay residents who received an antipsychotic medication	15.8%	19.8% 4 pts better	16.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.9% · Q3 18.9% · Q4 21.9% · 4Q avg 15.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 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	34.3%	18.5% 15.8 pts worse	16.3% 18 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q3 39.1% · Q4 29.6% · 4Q avg 34.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	30.2%	18.3% 11.9 pts worse	14.9% 15.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 11.6% · Q3 45.5% · Q4 23.7% · 4Q avg 30.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.7% 1.7 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.5% 2.5 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	25.8%	26.0% 0.2 pts better	19.8% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 30.4% · Q3 21.4% · Q4 20.6% · 4Q avg 25.8%
Percentage of long-stay residents with pressure ulcers	3.0%	4.3% 1.3 pts better	5.1% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.1% · Q3 2.5% · Q4 4.3% · 4Q avg 3.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	85.0%	84.3% 0.7 pts better	81.7% 3.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q3 90.9% · 4Q avg 85.0%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.9% 1.9 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	75.0%	73.3% 1.7 pts better	79.7% 4.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-21 · Fire 2024-11-21

31 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)

Cycle 2 Health 2023-08-31 · Fire 2023-08-31

21 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

15 fire-safety deficiencies

Top issue: Egress (5 deficiencies)

Cycle 3 Health 2022-06-03 · Fire 2022-06-03

18 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

12 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-21

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-11-27

F · Potential for more than minimal harm 2024-11-21

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2024-11-29

F · Potential for more than minimal harm 2024-11-21

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-12-02

F · Potential for more than minimal harm 2024-11-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-12-02

F · Potential for more than minimal harm 2024-11-21

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-12-05

E · Potential for more than minimal harm 2024-11-21

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 2024-12-11

E · Potential for more than minimal harm 2024-11-21

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-12-05

D · Potential for more than minimal harm 2024-11-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-11-27

F · Potential for more than minimal harm 2023-08-31

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2023-09-06

F · Potential for more than minimal harm 2023-08-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-09-06

E · Potential for more than minimal harm 2023-08-31

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2023-09-05

E · Potential for more than minimal harm 2023-08-31

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 2023-09-06

E · Potential for more than minimal harm 2023-08-31

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-09-06

E · Potential for more than minimal harm 2023-08-31

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-09-06

E · Potential for more than minimal harm 2023-08-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-09-06

E · Potential for more than minimal harm 2023-08-31

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-08-31

K922 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use and maintenance of medical gas equipment.

Corrected 2023-09-06

F · Potential for more than minimal harm 2022-06-03

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2022-06-06

F · Potential for more than minimal harm 2022-06-03

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-06-06

F · Potential for more than minimal harm 2022-06-03

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-06-03

K354 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-06-03

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-06-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-06-03

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-06-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-06-20

E · Potential for more than minimal harm 2022-06-03

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-03

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-03

K922 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use and maintenance of medical gas equipment.

Corrected 2022-06-20

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-08

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 2026-02-06

D · Potential for more than minimal harm 2026-01-08

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 2026-02-06

D · Potential for more than minimal harm 2025-11-05

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-12-18

D · Potential for more than minimal harm 2025-11-05

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-12-18

D · Potential for more than minimal harm 2025-11-05

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 2025-12-18

D · Potential for more than minimal harm 2025-10-15

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 2025-12-12

D · Potential for more than minimal harm 2025-10-15

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 2025-12-12

G · Actual harm 2025-07-09

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 2025-07-25

G · Actual harm 2025-07-09

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 2025-07-25

E · Potential for more than minimal harm 2025-07-09

F560 · Resident Rights Deficiencies

Health

Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

Corrected 2025-07-25

E · Potential for more than minimal harm 2025-07-09

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 2025-07-25

E · Potential for more than minimal harm 2025-07-09

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-07-25

E · Potential for more than minimal harm 2025-07-09

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-09

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 2025-07-25

D · Potential for more than minimal harm 2025-07-09

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 2025-07-25

D · Potential for more than minimal harm 2025-07-09

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 2025-07-25

D · Potential for more than minimal harm 2025-07-09

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-09

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 2025-07-25

D · Potential for more than minimal harm 2025-07-09

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 2025-07-09

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 2025-07-25

D · Potential for more than minimal harm 2025-07-09

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-07-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-25

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

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-10

F · Potential for more than minimal harm 2024-11-21

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2024-12-13

E · Potential for more than minimal harm 2024-11-21

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-12-13

E · Potential for more than minimal harm 2024-11-21

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 2024-12-13

E · Potential for more than minimal harm 2024-11-21

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-12-13

E · Potential for more than minimal harm 2024-11-21

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 2024-11-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

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 2024-12-13

D · Potential for more than minimal harm 2024-11-21

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 2024-12-13

E · Potential for more than minimal harm 2024-04-22

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-05-14

E · Potential for more than minimal harm 2024-04-22

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-04-22

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 2024-05-14

D · Potential for more than minimal harm 2024-04-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-14

G · Actual harm 2023-08-31

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-31

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-09-28

D · Potential for more than minimal harm 2023-08-31

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

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 2023-09-28

D · Potential for more than minimal harm 2023-08-31

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-09-28

D · Potential for more than minimal harm 2023-08-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-28

D · Potential for more than minimal harm 2023-07-11

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-07-20

G · Actual harm 2022-06-03

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-06-03

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 2022-06-24

F · Potential for more than minimal harm 2022-06-03

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 2022-06-24

F · Potential for more than minimal harm 2022-06-03

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

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 2022-06-24

D · Potential for more than minimal harm 2022-06-03

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

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 2022-06-24

D · Potential for more than minimal harm 2022-06-03

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

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 2022-06-24

D · Potential for more than minimal harm 2022-06-03

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-03

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 2022-06-24

C · Minimal harm 2022-06-03

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-06-24

C · Minimal harm 2022-06-03

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 2022-06-24

C · Minimal harm 2022-06-03