Cycle 1
Health 2025-09-04 · Fire 2025-09-04
75 health deficiencies
Top issue: Resident Rights (15 deficiencies)
20 fire-safety deficiencies
Top issue: Miscellaneous (5 deficiencies)
Easton, MD
Pines Nursing And Rehab
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $24,088 in total fines with 75 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
610 Dutchman's Lane, Easton, MD
(410) 822-4000
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
195
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Key Health Management
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 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
0.50
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,247
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0049
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 21.57% · Performance 16.93% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.34
Baseline 11.67% · Performance 7.11% · Measure score 6.34 · Achievement 2.43 · Improvement 6.34
Total nurse turnover
3.94
Baseline 84.91% · Performance 58.25% · Measure score 3.94 · Achievement 1.33 · Improvement 3.94
Adjusted total nurse staffing
0
Baseline 2.93 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 216 · Observed rate 14.81% · Lower 95% interval 9.31% |
| Discharge to community | 38.39% |
50.57%
12.2 pts worse
|
Worse than the National Rate · Eligible stays 208 · Observed rate 29.33% · Lower 95% interval 32.13% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.31% |
95.27%
4 pts better
|
Numerator 144 · Denominator 145 |
| Falls with major injury | 2.07% |
0.77%
1.3 pts worse
|
Numerator 3 · Denominator 145 |
| Discharge self-care score | 54.65% |
53.69%
1 pts better
|
Numerator 47 · Denominator 86 |
| Discharge mobility score | 56.98% |
50.94%
6 pts better
|
Numerator 49 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0.69% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 145 · Adjusted rate 0.51% |
| Healthcare-associated infections requiring hospitalization | 7.11% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 155 · Observed rate 7.74% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 1.95% |
8.2%
6.2 pts worse
|
Numerator 3 · Denominator 154 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 58.14% |
56.45%
1.7 pts better
|
Numerator 50 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 90 · Denominator 90 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.5% |
25.2%
7.7 pts worse
|
Numerator 14 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.9% |
91.9%
29 pts worse
|
93.4%
30.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.0% · Q2 58.4% · Q3 57.4% · Q4 71.0% · 4Q avg 62.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
96.6%
1.7 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
2.3%
3.4 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.9% · Q3 5.3% · Q4 4.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.9% |
21.4%
10.5 pts worse
|
11.4%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 33.8% · Q3 38.1% · Q4 23.1% · 4Q avg 31.9% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.7%
1.2 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 5.0% · Q3 1.1% · Q4 2.2% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
16.1%
7.3 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 25.3% · Q3 20.7% · Q4 26.0% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
15.3%
3.4 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 14.3% · Q3 13.8% · Q4 26.5% · 4Q avg 18.7% · 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 | 42.7% |
26.6%
16.1 pts worse
|
16.3%
26.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.7% · Q2 55.9% · Q3 17.5% · Q4 46.5% · 4Q avg 42.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.3% |
22.9%
14.4 pts worse
|
14.9%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 43.6% · Q3 38.8% · Q4 28.1% · 4Q avg 37.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.7%
0.5 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.9% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.5%
1 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 5.4% · Q4 2.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.6% |
25.4%
13.2 pts worse
|
19.8%
18.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 31.5% · Q3 42.0% · Q4 44.2% · 4Q avg 38.6% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.3%
1.2 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.2% · Q3 6.2% · Q4 6.9% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 30.6% |
78.4%
47.8 pts worse
|
81.7%
51.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 23.7% · Q3 13.3% · Q4 37.9% · 4Q avg 30.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
9.9%
3.4 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 14.8% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 3.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.0% |
80.6%
52.6 pts worse
|
79.7%
51.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 28.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
21.2%
6.1 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 17.4% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-28 · Fire 2022-09-28
64 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
27 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Cycle 3
Health 2018-10-25 · Fire 2018-10-25
28 health deficiencies
Top issue: Resident Rights (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-09-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-09-04
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-09-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-09-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-09-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
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 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-09-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-09-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-09-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-09-04
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-09-04
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 2025-11-07
D · Potential for more than minimal harm
2025-09-04
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-11-07
F · Potential for more than minimal harm
2022-09-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-09-28
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-24
F · Potential for more than minimal harm
2022-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-09-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-24
F · Potential for more than minimal harm
2022-09-28
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-09-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-09-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-24
F · Potential for more than minimal harm
2022-09-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
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 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-09-28
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2023-02-24
E · Potential for more than minimal harm
2022-09-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-09-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-09-28
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-09-28
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 2023-01-18
D · Potential for more than minimal harm
2022-09-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-09-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-09-28
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-09-28
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 2023-01-18
D · Potential for more than minimal harm
2022-09-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-01-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-04
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 2025-11-10
F · Potential for more than minimal harm
2025-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-10
F · Potential for more than minimal harm
2025-09-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-11-10
E · Potential for more than minimal harm
2025-09-04
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 2025-11-10
E · Potential for more than minimal harm
2025-09-04
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 2025-11-10
E · Potential for more than minimal harm
2025-09-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-11-10
E · Potential for more than minimal harm
2025-09-04
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 2025-11-10
E · Potential for more than minimal harm
2025-09-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-10
E · Potential for more than minimal harm
2025-09-04
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 2025-11-10
E · Potential for more than minimal harm
2025-09-04
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 2025-11-10
E · Potential for more than minimal harm
2025-09-04
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 2025-11-10
E · Potential for more than minimal harm
2025-09-04
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
D · Potential for more than minimal harm
2025-09-04
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 2025-11-10
J · Immediate jeopardy
2025-03-19
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 2025-05-27
G · Actual harm
2025-03-19
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 2025-05-27
F · Potential for more than minimal harm
2025-03-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-03-19
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 2025-05-27
F · Potential for more than minimal harm
2025-03-19
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-03-19
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-03-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-03-19
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 2025-06-20
E · Potential for more than minimal harm
2025-03-19
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 2025-06-20
E · Potential for more than minimal harm
2025-03-19
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 2025-05-27
E · Potential for more than minimal harm
2025-03-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-03-19
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 2025-06-20
E · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-03-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-03-19
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 2025-06-20
E · Potential for more than minimal harm
2025-03-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-03-19
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 2025-06-20
E · Potential for more than minimal harm
2025-03-19
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 2025-06-20
E · Potential for more than minimal harm
2025-03-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-03-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-03-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
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 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-03-19
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 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
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 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-03-19
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 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-03-19
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-03-19
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-05-27
C · Minimal harm
2025-03-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-27
K · Immediate jeopardy
2022-09-28
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-03-18
G · Actual harm
2022-09-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-27
F · Potential for more than minimal harm
2022-09-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-11-27
F · Potential for more than minimal harm
2022-09-28
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 2023-03-18
F · Potential for more than minimal harm
2022-09-28
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 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
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 2022-11-27
F · Potential for more than minimal harm
2022-09-28
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 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
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 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-11-27
F · Potential for more than minimal harm
2022-09-28
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 2022-11-27
F · Potential for more than minimal harm
2022-09-28
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
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 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-03
F · Potential for more than minimal harm
2022-09-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-11-27
F · Potential for more than minimal harm
2022-09-28
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-11-27
F · Potential for more than minimal harm
2022-09-28
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-11-27
F · Potential for more than minimal harm
2022-09-28
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 2023-03-03
E · Potential for more than minimal harm
2022-09-28
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 2022-11-27
E · Potential for more than minimal harm
2022-09-28
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 2022-11-27
E · Potential for more than minimal harm
2022-09-28
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 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-11-27
E · Potential for more than minimal harm
2022-09-28
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
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 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-18
E · Potential for more than minimal harm
2022-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-27
E · Potential for more than minimal harm
2022-09-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-11-27
E · Potential for more than minimal harm
2022-09-28
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 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-18
E · Potential for more than minimal harm
2022-09-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
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 2022-11-27
E · Potential for more than minimal harm
2022-09-28
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 2022-11-27
E · Potential for more than minimal harm
2022-09-28
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
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 2023-03-18
E · Potential for more than minimal harm
2022-09-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
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 2022-11-27
E · Potential for more than minimal harm
2022-09-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-11-27
E · Potential for more than minimal harm
2022-09-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-03
E · Potential for more than minimal harm
2022-09-28
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 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-03-03
D · Potential for more than minimal harm
2022-09-28
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 2022-11-27
D · Potential for more than minimal harm
2022-09-28
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 2023-03-03
D · Potential for more than minimal harm
2022-09-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-09-28
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-11-27
C · Minimal harm
2022-09-28
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-03-03
C · Minimal harm
2022-09-28
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 2023-03-03
C · Minimal harm
2022-09-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-11-27
C · Minimal harm
2022-09-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-27
E · Potential for more than minimal harm
2018-10-25
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-12-01
E · Potential for more than minimal harm
2018-10-25
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 2018-12-01
E · Potential for more than minimal harm
2018-10-25
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 2018-12-01
E · Potential for more than minimal harm
2018-10-25
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 2018-12-01
E · Potential for more than minimal harm
2018-10-25
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 2018-12-01
E · Potential for more than minimal harm
2018-10-25
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 2018-12-01
E · Potential for more than minimal harm
2018-10-25
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 2018-12-01
E · Potential for more than minimal harm
2018-10-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-05-10
D · Potential for more than minimal harm
2018-10-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
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 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-10-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2018-12-01
Penalties and ownership
What sits behind the stars
$24,088
2025-03-19
Fine
Fine · fine $24,088
Fine
Ownership
Md4 Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Hirth, Yechiel
5% Or Greater Indirect Ownership Interest · Individual
Gilligan, Dianna
Operational/Managerial Control · Individual
Hirth, Yechiel
Operational/Managerial Control · Individual
Howard, Daniel
Operational/Managerial Control · Individual
Nearby options
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#3
Mallard Bay Nursing And Rehab
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1-star overall rating with 1-star inspections with 48 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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