Cycle 1
Health 2025-09-19 · Fire 2025-09-19
53 health deficiencies
Top issue: Resident Rights (14 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Rochester, PA
Rochester Residence And Care Center
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $353,716 in total fines with 49 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
174 Virginia Avenue, Rochester, PA
(724) 775-6400
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pollak Holdings
Operator or chain grouping
Approved since
1988-04-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 1 health / 2 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
0.85
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.09
Baseline 58.25% · Performance 59.22% · Measure score 1.09 · Achievement 1.09 · Improvement 0
Adjusted total nurse staffing
0.80
Baseline 2.99 hours · Performance 3.31 hours · Measure score 0.80 · Achievement 0.80 · Improvement 0.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 7.15% |
| Discharge to community | 46.16% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 37.14% · Lower 95% interval 31.67% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 13 · Denominator 23 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 12 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 3.54% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 15 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.9% |
86.9%
25 pts worse
|
93.4%
31.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.1% · Q2 68.8% · Q3 59.2% · Q4 53.3% · 4Q avg 61.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
93.5%
3.1 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.8% · Q3 0.0% · Q4 4.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 16.8% |
6.5%
10.3 pts worse
|
5.4%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 18.8% · Q3 20.6% · Q4 14.1% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
19.9%
1.7 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.8% · Q3 19.0% · Q4 18.5% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
18.7%
2.4 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 17.6% · Q3 11.1% · Q4 16.4% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.4% |
19.6%
1.2 pts better
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 17.7% · Q3 13.9% · Q4 22.6% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
18.3%
5.3 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 14.1% · Q3 8.6% · Q4 18.0% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 0.0% · Q4 2.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
26.4%
0.2 pts better
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 30.0% · Q3 30.5% · Q4 21.6% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.3%
0.7 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.2% · Q3 5.8% · Q4 5.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 12.1% |
68.9%
56.8 pts worse
|
81.7%
69.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 13.7% · Q3 7.3% · Q4 9.0% · 4Q avg 12.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
9.8%
3.3 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.1% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.4% · Q3 3.4% · Q4 1.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 20.9% |
68.7%
47.8 pts worse
|
79.7%
58.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 20.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
23.1%
5.7 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 32.1% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-03-21 · Fire 2025-03-21
47 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2024-06-07 · Fire 2024-06-07
38 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-19
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-19
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-19
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 2025-10-15
D · Potential for more than minimal harm
2025-09-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-10-15
C · Minimal harm
2025-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-03-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-23
E · Potential for more than minimal harm
2024-06-07
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 2024-08-06
E · Potential for more than minimal harm
2024-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-06-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-06-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-06-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-06
C · Minimal harm
2024-06-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-06
Inspection history
Recent health citations
L · Immediate jeopardy
2026-01-31
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.
Not marked corrected
F · Potential for more than minimal harm
2026-01-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Not marked corrected
D · Potential for more than minimal harm
2026-01-31
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Not marked corrected
D · Potential for more than minimal harm
2026-01-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Not marked corrected
D · Potential for more than minimal harm
2026-01-31
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-31
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Not marked corrected
D · Potential for more than minimal harm
2026-01-31
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Not marked corrected
F · Potential for more than minimal harm
2025-09-19
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 2025-10-30
F · Potential for more than minimal harm
2025-09-19
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 2025-10-30
F · Potential for more than minimal harm
2025-09-19
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 2025-10-30
F · Potential for more than minimal harm
2025-09-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-30
F · Potential for more than minimal harm
2025-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
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 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
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 2025-10-30
E · Potential for more than minimal harm
2025-09-19
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 2025-10-30
E · Potential for more than minimal harm
2025-09-19
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 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-10-30
D · Potential for more than minimal harm
2025-09-19
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-10-30
F · Potential for more than minimal harm
2025-08-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-08-12
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 2025-09-03
D · Potential for more than minimal harm
2025-08-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-06-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-03
J · Immediate jeopardy
2025-05-15
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-29
G · Actual harm
2025-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-29
G · Actual harm
2025-05-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-15
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 2025-05-29
D · Potential for more than minimal harm
2025-05-15
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 2025-05-29
J · Immediate jeopardy
2025-03-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-03-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
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 2025-04-23
E · Potential for more than minimal harm
2025-03-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-21
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 2025-04-23
E · Potential for more than minimal harm
2025-03-21
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 2025-04-23
E · Potential for more than minimal harm
2025-03-21
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 2025-04-23
D · Potential for more than minimal harm
2025-03-21
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 2025-04-23
D · Potential for more than minimal harm
2025-03-21
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 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
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 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
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 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-21
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-02-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-02-26
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 2025-04-02
D · Potential for more than minimal harm
2025-02-26
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 2025-04-02
D · Potential for more than minimal harm
2025-02-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-01-28
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 2025-03-15
D · Potential for more than minimal harm
2025-01-28
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-01-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-01-28
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 2025-03-15
F · Potential for more than minimal harm
2024-12-17
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 2025-01-09
F · Potential for more than minimal harm
2024-12-17
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-12-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-19
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 2024-12-13
E · Potential for more than minimal harm
2024-11-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-09-23
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 2024-10-18
D · Potential for more than minimal harm
2024-09-23
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 2024-10-18
D · Potential for more than minimal harm
2024-09-23
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 2024-10-18
D · Potential for more than minimal harm
2024-09-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-18
G · Actual harm
2024-08-13
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 2024-09-06
G · Actual harm
2024-08-13
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 2024-09-06
D · Potential for more than minimal harm
2024-08-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-06
F · Potential for more than minimal harm
2024-06-07
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 2024-07-31
E · Potential for more than minimal harm
2024-06-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-07
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 2024-07-31
E · Potential for more than minimal harm
2024-06-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
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 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-31
D · Potential for more than minimal harm
2023-10-16
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 2023-11-28
D · Potential for more than minimal harm
2023-10-16
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 2023-11-28
D · Potential for more than minimal harm
2023-10-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-28
J · Immediate jeopardy
2023-05-19
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 2023-06-16
J · Immediate jeopardy
2023-04-28
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 2023-06-08
K · Immediate jeopardy
2023-03-30
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 2023-05-03
J · Immediate jeopardy
2023-03-30
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-30
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 2023-05-03
F · Potential for more than minimal harm
2023-03-30
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.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-30
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-30
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 2023-05-03
Penalties and ownership
What sits behind the stars
$0
2025-09-19
Payment Denial
Payment Denial · denial start 2025-11-22 · 26 days
26 day denial
$17,443
2025-05-15
Fine
Fine · fine $17,443
Fine
$286,709
2025-01-28
Fine
Fine · fine $286,709
Fine
$8,772
2024-06-07
Fine
Fine · fine $8,772
Fine
$8,773
2024-06-07
Fine
Fine · fine $8,773
Fine
$32,019
2023-12-18
Fine
Fine · fine $32,019
Fine
Ownership
Hunter, Sarah
Operational/Managerial Control · Individual
Pollak, Elie
Corporate Director · Individual
Pollak, Theodore
Corporate Director · Individual
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