Cycle 1
Health 2024-11-14 · Fire 2024-11-14
27 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Evansville, IN
River Bend Nursing And Rehabilitation
1-star overall rating with 1-star inspections with 27 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
3400 Stocker Dr, Evansville, IN
(812) 424-8100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Adams County Memorial Hospital
Operator or chain grouping
Approved since
1997-04-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.67
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,117
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 22.86% · Performance 20.48% · Measure score 3.58 · Achievement 2.05 · Improvement 3.58
Healthcare-associated infections
0
Baseline 6.87% · Performance 8.18% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.61
Baseline 87.10% · Performance 61.54% · Measure score 3.61 · Achievement 0.52 · Improvement 3.61
Adjusted total nurse staffing
0
Baseline 3.17 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.89% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 10.17% · Lower 95% interval 6.34% |
| Discharge to community | 38.45% |
50.57%
12.1 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 27.03% · Lower 95% interval 24.33% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 31 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 47.62% |
53.69%
6.1 pts worse
|
Numerator 10 · Denominator 21 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 7 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 3.85% |
| Healthcare-associated infections requiring hospitalization | 8.18% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 14.63% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 2.11% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 95 |
| Staff flu vaccination coverage | 29.36% |
42%
12.6 pts worse
|
Numerator 32 · Denominator 109 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.5
1.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
93.6%
6 pts worse
|
93.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 93.1% · Q3 86.2% · Q4 78.0% · 4Q avg 87.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
95.4%
3 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.8%
0.5 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.2% · Q3 3.4% · Q4 5.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.7% |
24.6%
9.9 pts better
|
11.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.8% · Q3 24.4% · Q4 16.7% · 4Q avg 14.7% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.6%
2 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 3.8% · Q3 12.0% · Q4 7.3% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.7% |
23.5%
12.2 pts worse
|
19.6%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 34.0% · Q3 37.3% · Q4 32.7% · 4Q avg 35.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
14.8%
2.8 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 9.8% · Q3 12.2% · Q4 9.3% · 4Q avg 12.0% · 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 | 22.5% |
13.3%
9.2 pts worse
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 34.1% · Q3 22.9% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
11.7%
10.6 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 32.0% · Q3 31.9% · Q4 10.9% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.1% · Q3 1.3% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
1.2%
4.4 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.5% · Q3 8.6% · Q4 3.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
24.2%
2.4 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 23.7% · Q3 28.1% · Q4 23.9% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 9.6% |
4.1%
5.5 pts worse
|
5.1%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 12.6% · Q3 3.8% · Q4 8.1% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.4% |
81.6%
43.2 pts worse
|
81.7%
43.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.0% · Q3 29.6% · Q4 29.3% · 4Q avg 38.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.2% |
10.5%
7.3 pts better
|
12.0%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.2% · Observed 3.7% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.9% |
79.0%
36.1 pts worse
|
79.7%
36.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.9% |
22.4%
12.5 pts better
|
23.9%
14 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 11.1% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-11 · Fire 2023-09-11
17 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
23 fire-safety deficiencies
Top issue: Smoke (11 deficiencies)
Cycle 3
Health 2021-08-24 · Fire 2021-08-24
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-14
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-11-14
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 2024-12-30
E · Potential for more than minimal harm
2024-11-14
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 2024-12-30
E · Potential for more than minimal harm
2024-11-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-11-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-11-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-30
B · Minimal harm
2024-11-14
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 2024-12-30
F · Potential for more than minimal harm
2023-09-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-09-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-02
C · Minimal harm
2023-09-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-11-02
C · Minimal harm
2023-09-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-11-02
C · Minimal harm
2023-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-02
F · Potential for more than minimal harm
2021-08-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-11-30
F · Potential for more than minimal harm
2021-08-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-11-30
F · Potential for more than minimal harm
2021-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
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 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-08-24
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-30
C · Minimal harm
2021-08-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-11-30
C · Minimal harm
2021-08-24
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 2021-11-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-30
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-30
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2025-11-25
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 2025-12-17
D · Potential for more than minimal harm
2025-11-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-11-25
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-12-17
E · Potential for more than minimal harm
2024-11-14
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 2024-12-13
E · Potential for more than minimal harm
2024-11-14
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 2024-12-13
E · Potential for more than minimal harm
2024-11-14
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
2024-11-14
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
2024-11-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-14
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
2024-11-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-13
G · Actual harm
2024-09-10
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 2024-08-31
E · Potential for more than minimal harm
2024-06-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-14
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 2024-05-30
D · Potential for more than minimal harm
2024-03-01
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 2024-03-22
D · Potential for more than minimal harm
2023-11-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
E · Potential for more than minimal harm
2023-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-09-11
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 2023-11-02
D · Potential for more than minimal harm
2023-09-11
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 2023-11-02
D · Potential for more than minimal harm
2023-09-11
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 2023-11-02
D · Potential for more than minimal harm
2023-09-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-02
C · Minimal harm
2023-09-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-07
C · Minimal harm
2023-09-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-04-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-05-12
E · Potential for more than minimal harm
2021-08-24
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 2021-09-25
E · Potential for more than minimal harm
2021-08-24
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2021-09-25
E · Potential for more than minimal harm
2021-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-25
D · Potential for more than minimal harm
2021-08-24
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 2021-09-25
D · Potential for more than minimal harm
2021-08-24
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 2021-09-25
D · Potential for more than minimal harm
2021-08-24
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 2021-09-25
D · Potential for more than minimal harm
2021-08-24
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 2021-09-25
D · Potential for more than minimal harm
2021-08-24
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 2021-09-25
D · Potential for more than minimal harm
2021-08-24
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 2021-09-25
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Smith, Scott
Corporate Officer · Individual
Smith, Scott
W-2 Managing Employee · Individual
Sprunger, Kyle
Corporate Officer · Individual
Sprunger, Kyle
W-2 Managing Employee · Individual
Wheeler, Dane
Corporate Officer · Individual
Wheeler, Dane
W-2 Managing Employee · Individual
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