Cycle 1
Health 2024-10-23 · Fire 2024-10-23
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Plymouth, MA
Plymouth Harborside Healthcare
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $460,269 in total fines with 20 recent health deficiencies
19 Obery Street, Plymouth, MA
(508) 747-4790
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Next Step Healthcare
Operator or chain grouping
Approved since
1985-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 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
0.60
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,262
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.87% · Performance 24.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.15
Baseline 9.05% · Performance 7.97% · Measure score 2.15 · Achievement 0 · Improvement 2.15
Total nurse turnover
0
Baseline 45.00% · Performance 64.21% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.67
Baseline 3.08 hours · Performance 3.27 hours · Measure score 0.67 · Achievement 0.67 · Improvement 0.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 11.93% · Lower 95% interval 6.9% |
| Discharge to community | 43.04% |
50.57%
7.5 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 34.48% · Lower 95% interval 32.03% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.82% |
95.27%
3.5 pts better
|
Numerator 84 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 21.57% |
53.69%
32.1 pts worse
|
Numerator 11 · Denominator 51 |
| Discharge mobility score | 37.25% |
50.94%
13.7 pts worse
|
Numerator 19 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 10.59% |
2.29%
8.3 pts worse
|
Numerator 9 · Denominator 85 · Adjusted rate 8.45% |
| Healthcare-associated infections requiring hospitalization | 7.97% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 11.11% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 35.05% |
42%
7 pts worse
|
Numerator 34 · Denominator 97 |
| Discharge function score | 37.25% |
56.45%
19.2 pts worse
|
Numerator 19 · Denominator 51 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 55.81% |
25.2%
30.6 pts better
|
Numerator 24 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 5.1 |
1.9
3.2 pts worse
|
1.9
3.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.1 · Observed 4.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.5
1.4 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
92.2%
5.2 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 97.3% · Q3 98.7% · Q4 97.4% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.5%
0.8 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.4% · Q3 3.8% · Q4 3.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.9% |
12.0%
8.9 pts worse
|
11.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.0% · Q3 20.6% · Q4 20.9% · 4Q avg 20.9% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.2%
1.3 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.1% · Q3 10.1% · Q4 6.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
19.2%
7.5 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 22.7% · Q3 28.2% · Q4 31.0% · 4Q avg 26.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.1% |
22.5%
2.6 pts worse
|
16.7%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 20.4% · Q3 27.3% · Q4 27.8% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.6% |
17.7%
12.1 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 0.0% · Q3 9.2% · Q4 7.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
17.6%
5.1 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 16.7% · Q3 15.2% · Q4 9.1% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.2% |
2.0%
4.2 pts worse
|
1.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 6.0% · Q3 7.8% · Q4 9.5% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.0% |
21.7%
6.7 pts better
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 18.7% · Q3 18.8% · Q4 16.0% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.6%
1.5 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.0% · Q3 6.0% · Q4 5.5% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.7% |
77.1%
9.4 pts worse
|
81.7%
14 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.3% · Q2 63.6% · Q3 66.0% · Q4 73.5% · 4Q avg 67.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.1% |
11.8%
10.3 pts worse
|
12.0%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 25.7% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
77.7%
4.4 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.8% |
25.8%
7 pts worse
|
23.9%
8.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.8% · Observed 33.8% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
21 health deficiencies
Top issue: Resident Rights (7 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2021-03-18 · Fire 2021-03-18
24 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-08-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-30
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-04
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 2025-12-26
G · Actual harm
2025-09-16
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 2025-10-06
D · Potential for more than minimal harm
2025-09-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-16
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 2025-10-06
G · Actual harm
2025-08-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-22
G · Actual harm
2025-08-05
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 2025-08-22
F · Potential for more than minimal harm
2024-10-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-23
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 2024-11-25
D · Potential for more than minimal harm
2024-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-23
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 2024-11-15
D · Potential for more than minimal harm
2024-10-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-23
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 2024-11-15
B · Minimal harm
2024-10-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-25
G · Actual harm
2023-11-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-06
G · Actual harm
2023-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-06
J · Immediate jeopardy
2023-10-11
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 2023-10-21
J · Immediate jeopardy
2023-10-11
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 2023-10-21
G · Actual harm
2023-08-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
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 2023-10-23
E · Potential for more than minimal harm
2023-08-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-30
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 2023-10-02
D · Potential for more than minimal harm
2023-08-30
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 2023-10-02
D · Potential for more than minimal harm
2023-08-30
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-08-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-08-30
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 2023-10-02
D · Potential for more than minimal harm
2023-08-30
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-02
B · Minimal harm
2023-08-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-02
F · Potential for more than minimal harm
2021-03-18
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2021-05-05
F · Potential for more than minimal harm
2021-03-18
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 2021-06-16
F · Potential for more than minimal harm
2021-03-18
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2021-05-05
F · Potential for more than minimal harm
2021-03-18
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 2021-06-04
F · Potential for more than minimal harm
2021-03-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-07-01
F · Potential for more than minimal harm
2021-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-01
F · Potential for more than minimal harm
2021-03-18
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-07-01
E · Potential for more than minimal harm
2021-03-18
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2021-05-05
E · Potential for more than minimal harm
2021-03-18
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 2021-05-05
E · Potential for more than minimal harm
2021-03-18
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 2021-06-04
E · Potential for more than minimal harm
2021-03-18
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 2021-05-05
D · Potential for more than minimal harm
2021-03-18
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 2021-05-05
D · Potential for more than minimal harm
2021-03-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-05-05
D · Potential for more than minimal harm
2021-03-18
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 2021-05-05
D · Potential for more than minimal harm
2021-03-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-05-05
D · Potential for more than minimal harm
2021-03-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-05
D · Potential for more than minimal harm
2021-03-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-05
D · Potential for more than minimal harm
2021-03-18
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 2021-05-05
D · Potential for more than minimal harm
2021-03-18
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 2021-05-05
D · Potential for more than minimal harm
2021-03-18
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2021-05-05
Penalties and ownership
What sits behind the stars
$97,500
2026-02-13
Fine
Fine · fine $97,500
Fine
$304,580
2025-09-16
Fine
Fine · fine $304,580
Fine
$15,935
2025-08-05
Fine
Fine · fine $15,935
Fine
$11,638
2023-11-14
Fine
Fine · fine $11,638
Fine
$15,269
2023-08-30
Fine
Fine · fine $15,269
Fine
$15,347
2023-08-30
Fine
Fine · fine $15,347
Fine
Ownership
Next Step Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Dell'anno, Damian
5% Or Greater Indirect Ownership Interest · Individual
Stephan, William
5% Or Greater Indirect Ownership Interest · Individual
Dell'anno, Damian
Corporate Officer · Individual
Next Step Healthcare LLC
Operational/Managerial Control · Organization
Nguyen, Nina
Operational/Managerial Control · Individual
Rattan, Rohit
Operational/Managerial Control · Individual
Stephan, William
Corporate Officer · Individual
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