Cycle 1
Health 2024-10-11 · Fire 2024-10-11
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Morris, IL
Serenity Estates At Morris
1-star overall rating with 3-star inspections with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1223 Edgewater, Morris, IL
(815) 416-6500
Overall
1 / 5
CMS overall stars
Health inspections
3 / 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
142
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-02-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.65
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
2.77
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,292
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.20
Baseline 21.82% · Performance 18.13% · Measure score 7.20 · Achievement 7.12 · Improvement 7.20
Healthcare-associated infections
2.82
Baseline 5.06% · Performance 6.99% · Measure score 2.82 · Achievement 2.82 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.76 hours · Performance 2.84 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.49% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 197 · Observed rate 12.69% · Lower 95% interval 9.07% |
| Discharge to community | 47.97% |
50.57%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 46.39% · Lower 95% interval 42.25% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.57% |
95.27%
3.3 pts better
|
Numerator 138 · Denominator 140 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 140 |
| Discharge self-care score | 42.11% |
53.69%
11.6 pts worse
|
Numerator 40 · Denominator 95 |
| Discharge mobility score | 35.79% |
50.94%
15.1 pts worse
|
Numerator 34 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 140 · Adjusted rate 4.2% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 5.1% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 7.89% |
8.2%
0.3 pts worse
|
Numerator 12 · Denominator 152 |
| Staff flu vaccination coverage | 44.35% |
42%
2.4 pts better
|
Numerator 55 · Denominator 124 |
| Discharge function score | 37.89% |
56.45%
18.6 pts worse
|
Numerator 36 · Denominator 95 |
| Transfer of health information to provider | 91.8% |
95.95%
4.2 pts worse
|
Numerator 56 · Denominator 61 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 15 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.0
1.2 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.9 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.3
1.1 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
89.6%
0.6 pts better
|
93.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.6% · Q2 98.7% · Q3 94.5% · Q4 87.6% · 4Q avg 90.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
91.6%
3.5 pts better
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.3%
2.5 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.1% · Q3 9.9% · Q4 5.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
50.3%
38.8 pts better
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.9% · Q3 3.8% · Q4 27.1% · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 12.1% · Q3 6.1% · Q4 4.2% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
18.5%
6.4 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 24.6% · Q3 23.3% · Q4 27.0% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
22.8%
2.4 pts better
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 14.6% · Q3 18.6% · Q4 26.7% · 4Q avg 20.4% · 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 | 37.3% |
17.2%
20.1 pts worse
|
16.3%
21 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 38.6% · Q4 32.5% · 4Q avg 37.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.9% |
15.0%
21.9 pts worse
|
14.9%
22 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 39.3% · Q3 34.7% · Q4 40.5% · 4Q avg 36.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.1%
0.8 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.5% · Q3 1.6% · Q4 1.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
1.7%
4.8 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.7% · Q3 8.3% · Q4 11.5% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
21.3%
12.5 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 37.5% · Q3 34.9% · Q4 30.4% · 4Q avg 33.8% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.7% · Q3 3.3% · Q4 0.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.2% |
68.8%
4.6 pts worse
|
81.7%
17.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.2% · Q2 65.4% · Q3 73.3% · Q4 69.3% · 4Q avg 64.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
14.0%
3.3 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 16.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
2.3%
0.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.2% · Q3 4.1% · Q4 3.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.9% |
63.0%
7.9 pts better
|
79.7%
8.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
26.2%
6.8 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 31.7% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-07-08 · Fire 2022-07-08
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-10-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-10-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-10-11
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 2024-10-17
E · Potential for more than minimal harm
2024-10-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-10-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-28
F · Potential for more than minimal harm
2023-09-28
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-09-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-09-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-09-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-09-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
C · Minimal harm
2023-09-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-03
F · Potential for more than minimal harm
2022-07-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-05
F · Potential for more than minimal harm
2022-07-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-21
F · Potential for more than minimal harm
2022-07-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-07-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-07-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-02
F · Potential for more than minimal harm
2022-07-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-07-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-07-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-18
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 2025-12-31
D · Potential for more than minimal harm
2025-08-13
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 2025-08-15
D · Potential for more than minimal harm
2025-05-02
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 2025-05-08
D · Potential for more than minimal harm
2025-01-17
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 2025-01-23
G · Actual harm
2024-10-26
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 2024-11-12
F · Potential for more than minimal harm
2024-10-11
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 2024-10-21
F · Potential for more than minimal harm
2024-10-11
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-10-11
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 2024-10-21
E · Potential for more than minimal harm
2024-10-11
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 2024-11-12
E · Potential for more than minimal harm
2024-10-11
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 2024-10-23
E · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-10-11
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 2024-10-23
D · Potential for more than minimal harm
2024-10-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-10-11
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 2024-10-23
D · Potential for more than minimal harm
2024-10-11
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 2024-10-22
D · Potential for more than minimal harm
2024-10-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-10-11
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 2024-10-21
C · Minimal harm
2024-10-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-18
C · Minimal harm
2024-10-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-10-18
D · Potential for more than minimal harm
2023-12-28
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 2024-01-08
F · Potential for more than minimal harm
2023-09-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-09
E · Potential for more than minimal harm
2023-09-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-09
E · Potential for more than minimal harm
2023-09-28
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 2023-10-09
D · Potential for more than minimal harm
2023-09-28
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-28
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-08-05
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 2023-08-19
D · Potential for more than minimal harm
2023-08-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-19
D · Potential for more than minimal harm
2023-07-24
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 2023-08-19
D · Potential for more than minimal harm
2023-07-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-04-15
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-04-20
F · Potential for more than minimal harm
2022-07-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-08
E · Potential for more than minimal harm
2022-07-08
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 2022-07-21
E · Potential for more than minimal harm
2022-07-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-08
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 2022-07-21
Penalties and ownership
What sits behind the stars
Ownership
Coglianese, John
Operational/Managerial Control · Individual
Daugherty, Jennifer
Operational/Managerial Control · Individual
Day, Suzanne
Operational/Managerial Control · Individual
Gs Management LLC
Operational/Managerial Control · Organization
Roumeliotis, Peter
Operational/Managerial Control · Individual
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