Cycle 1
Health 2024-11-15 · Fire 2024-11-15
29 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Wilmington, DE
Springs Rehabilitation At Brandywine
2-star overall rating with 1-star inspections with $99,184 in total fines with 29 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
505 Greenbank Road, Wilmington, DE
(302) 998-0101
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
169
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 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
0.58
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,599
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.97
Baseline 16.68% · Performance 20.52% · Measure score 1.97 · Achievement 1.97 · Improvement 0
Healthcare-associated infections
0
Baseline 6.55% · Performance 8.32% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.81
Baseline 59.26% · Performance 60.38% · Measure score 0.81 · Achievement 0.81 · Improvement 0
Adjusted total nurse staffing
1.84
Baseline 3.75 hours · Performance 3.60 hours · Measure score 1.84 · Achievement 1.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.61% |
10.72%
3.1 pts better
|
Better than the National Rate · Eligible stays 302 · Observed rate 5.3% · Lower 95% interval 5.51% |
| Discharge to community | 51.96% |
50.57%
1.4 pts better
|
No Different than the National Rate · Eligible stays 295 · Observed rate 43.39% · Lower 95% interval 46.53% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 95.85% |
95.27%
0.6 pts better
|
Numerator 208 · Denominator 217 |
| Falls with major injury | 0.46% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 217 |
| Discharge self-care score | 60.29% |
53.69%
6.6 pts better
|
Numerator 82 · Denominator 136 |
| Discharge mobility score | 44.85% |
50.94%
6.1 pts worse
|
Numerator 61 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 1.84% |
2.29%
0.4 pts better
|
Numerator 4 · Denominator 217 · Adjusted rate 1.53% |
| Healthcare-associated infections requiring hospitalization | 8.32% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 206 · Observed rate 10.19% · Lower 95% interval 6.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 157 |
| Staff flu vaccination coverage | 78.85% |
42%
36.8 pts better
|
Numerator 164 · Denominator 208 |
| Discharge function score | 60.29% |
56.45%
3.8 pts better
|
Numerator 82 · Denominator 136 |
| Transfer of health information to provider | 76.6% |
95.95%
19.4 pts worse
|
Numerator 72 · Denominator 94 |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 64 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 17.7% |
25.2%
7.5 pts worse
|
Numerator 20 · Denominator 113 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
95.7%
0.7 pts worse
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 97.6% · Q3 97.6% · Q4 97.6% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.4%
1.1 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.0% · Q3 4.0% · Q4 4.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
6.5%
About the same
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.7% · Q3 6.5% · Q4 12.6% · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.6%
0.2 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.0% · Q3 8.0% · Q4 4.8% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
21.1%
0.8 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 18.3% · Q3 21.7% · Q4 22.7% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
12.0%
6.4 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 17.7% · Q3 19.1% · Q4 19.0% · 4Q avg 18.4% · 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 | 9.6% |
17.5%
7.9 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 5.1% · Q3 13.5% · Q4 2.3% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
14.7%
5.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 12.4% · Q3 9.0% · Q4 5.4% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.0%
1 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.9% · Q3 3.3% · Q4 5.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
21.6%
0.6 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 22.3% · Q3 29.6% · Q4 22.7% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.4%
1.8 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.4% · Q3 2.3% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
83.5%
14.1 pts worse
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.2% · Q2 79.4% · Q3 69.7% · Q4 59.6% · 4Q avg 69.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
11.2%
5 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.6% |
83.1%
1.5 pts worse
|
79.7%
1.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
21.5%
1 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 22.8% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
23 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-05-06 · Fire 2021-05-06
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-12
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-10
E · Potential for more than minimal harm
2024-11-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-11-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-11-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-15
E · Potential for more than minimal harm
2023-11-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
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 2026-01-22
D · Potential for more than minimal harm
2025-12-08
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 2026-01-22
D · Potential for more than minimal harm
2025-12-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-08
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 2026-01-22
G · Actual harm
2024-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-02
G · Actual harm
2024-11-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-15
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 2025-01-02
E · Potential for more than minimal harm
2024-11-15
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 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
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 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
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 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
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 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
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 2025-01-02
D · Potential for more than minimal harm
2024-11-15
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-01-02
C · Minimal harm
2024-11-15
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-01-02
J · Immediate jeopardy
2023-11-08
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 2022-09-19
G · Actual harm
2023-11-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-08
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 2023-12-26
F · Potential for more than minimal harm
2023-11-08
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 2024-01-03
E · Potential for more than minimal harm
2023-11-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-11-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-11-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-08
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-08
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 2023-12-26
D · Potential for more than minimal harm
2023-11-08
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 2023-12-26
D · Potential for more than minimal harm
2023-11-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-08
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-08
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 2023-12-26
D · Potential for more than minimal harm
2023-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-08
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 2024-01-03
D · Potential for more than minimal harm
2023-11-08
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 2024-01-03
D · Potential for more than minimal harm
2023-11-08
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-08
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-08
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 2023-12-26
D · Potential for more than minimal harm
2023-11-08
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-12-26
B · Minimal harm
2023-11-08
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 2024-01-03
E · Potential for more than minimal harm
2021-05-06
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-06-21
E · Potential for more than minimal harm
2021-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-06
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 2021-06-21
D · Potential for more than minimal harm
2021-05-06
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-06-21
Penalties and ownership
What sits behind the stars
$76,148
2024-11-15
Fine
Fine · fine $76,148
Fine
$7,443
2023-11-08
Fine
Fine · fine $7,443
Fine
$15,593
2023-11-08
Fine
Fine · fine $15,593
Fine
Ownership
Coral Springs LLC
5% Or Greater Direct Ownership Interest · Organization
Comegys, Susan
W-2 Managing Employee · Individual
De Noble Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Srab Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Stern, Moshe
5% Or Greater Indirect Ownership Interest · Individual
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