Steubenville, OH

Steubenville Country Club Manor

1-star overall rating with 1-star inspections with $135,828 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

575 Lovers Lane, Steubenville, OH

(740) 266-6118

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2002-05-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.56

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.63

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.45

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.64

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.19

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.96

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.52

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

70%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,502

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

11.92

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

0.75

Baseline 21.62% · Performance 21.08% · Measure score 0.75 · Achievement 0.75 · Improvement 0.67

Healthcare-associated infections

Baseline 7.73% · Performance 7.94% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.65

Baseline 56.00% · Performance 52.83% · Measure score 2.65 · Achievement 2.65 · Improvement 0.52

Adjusted total nurse staffing

1.36

Baseline 3.61 hours · Performance 3.47 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.91%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 61 · Observed rate 11.48% · Lower 95% interval 7.31%
Discharge to community	44.47%	50.57% 6.1 pts worse	No Different than the National Rate · Eligible stays 46 · Observed rate 36.96% · Lower 95% interval 31.97%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	90.91%	95.27% 4.4 pts worse	Numerator 20 · Denominator 22
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 22
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 22 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.94%	7.12% 0.8 pts worse	No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 3.98%
Staff COVID-19 vaccination coverage	8.99%	8.2% 0.8 pts better	Numerator 8 · Denominator 89
Staff flu vaccination coverage	25%	42% 17 pts worse	Numerator 26 · Denominator 104
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
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 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.7	1.8 0.9 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.6 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.3	1.8 0.5 pts worse	1.8 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	53.1%	92.4% 39.3 pts worse	93.4% 40.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 47.5% · Q3 47.1% · Q4 72.9% · 4Q avg 53.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	68.2%	94.5% 26.3 pts worse	95.5% 27.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 68.2%
Percentage of long-stay residents experiencing one or more falls with major injury	7.4%	3.3% 4.1 pts worse	3.3% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.5% · Q3 8.8% · Q4 8.3% · 4Q avg 7.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	26.1% 26.1 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	11.4%	6.2% 5.2 pts worse	5.4% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 11.8% · Q3 12.9% · Q4 8.3% · 4Q avg 11.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	30.0%	25.4% 4.6 pts worse	19.6% 10.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 31.4% · Q3 35.5% · Q4 33.3% · 4Q avg 30.0%
Percentage of long-stay residents who received an antipsychotic medication	4.7%	11.5% 6.8 pts better	16.7% 12 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.3% · Q3 8.7% · Q4 3.6% · 4Q avg 4.7% · 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	31.0%	7.7% 23.3 pts worse	16.3% 14.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 31.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.4%	6.2% 18.2 pts worse	14.9% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 26.7% · Q3 20.8% · Q4 22.9% · 4Q avg 24.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	0.2% 1 pts worse	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.7%	0.5% 0.2 pts worse	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.9%	21.7% 9.2 pts worse	19.8% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 39.1% · Q2 25.1% · Q3 24.8% · Q4 33.4% · 4Q avg 30.9%
Percentage of long-stay residents with pressure ulcers	4.9%	3.7% 1.2 pts worse	5.1% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.4% · Q3 4.5% · Q4 3.2% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	40.2%	78.1% 37.9 pts worse	81.7% 41.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 27.3% · Q3 55.3% · Q4 54.5% · 4Q avg 40.2%
Percentage of short-stay residents who had an outpatient emergency department visit	3.5%	12.5% 9 pts better	12.0% 8.5 pts better	Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 3.4% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	34.8%	75.6% 40.8 pts worse	79.7% 44.9 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 34.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.0%	25.1% 3.1 pts better	23.9% 1.9 pts better	Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 24.1% · Expected 26.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-13 · Fire 2025-02-13

7 health deficiencies

Top issue: Infection Control (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-09-12 · Fire 2022-09-12

39 health deficiencies

Top issue: Quality of Life and Care (12 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2019-11-27 · Fire 2019-11-27

40 health deficiencies

Top issue: Quality of Life and Care (13 deficiencies)

15 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-13

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-04-18

F · Potential for more than minimal harm 2025-02-13

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-18

F · Potential for more than minimal harm 2025-02-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-18

F · Potential for more than minimal harm 2025-02-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-04-18

F · Potential for more than minimal harm 2025-02-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-18

E · Potential for more than minimal harm 2025-02-13

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-04-18

E · Potential for more than minimal harm 2025-02-13

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-04-18

E · Potential for more than minimal harm 2025-02-13

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-04-18

E · Potential for more than minimal harm 2025-02-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-04-18

F · Potential for more than minimal harm 2022-09-12

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2022-10-31

F · Potential for more than minimal harm 2022-09-12

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-10-31

E · Potential for more than minimal harm 2022-09-12

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-10-31

F · Potential for more than minimal harm 2019-11-27

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2020-03-14

F · Potential for more than minimal harm 2019-11-27

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2020-03-14

F · Potential for more than minimal harm 2019-11-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2020-03-14

F · Potential for more than minimal harm 2019-11-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2020-02-07

F · Potential for more than minimal harm 2019-11-27

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2020-02-07

F · Potential for more than minimal harm 2019-11-27

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2020-02-07

F · Potential for more than minimal harm 2019-11-27

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2020-02-07

F · Potential for more than minimal harm 2019-11-27

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2020-03-14

F · Potential for more than minimal harm 2019-11-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-03-14

E · Potential for more than minimal harm 2019-11-27

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2020-02-07

E · Potential for more than minimal harm 2019-11-27

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2020-02-07

E · Potential for more than minimal harm 2019-11-27

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2020-02-07

E · Potential for more than minimal harm 2019-11-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2020-03-14

E · Potential for more than minimal harm 2019-11-27

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2020-02-07

E · Potential for more than minimal harm 2019-11-27

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2020-02-07

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-13

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 2025-03-31

D · Potential for more than minimal harm 2025-02-13

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-13

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-13

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 2025-03-31

D · Potential for more than minimal harm 2025-02-13

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-13

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-13

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 2025-03-31

D · Potential for more than minimal harm 2024-10-02

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-10-30

D · Potential for more than minimal harm 2024-10-02

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 2024-10-30

F · Potential for more than minimal harm 2024-05-30

F728 · Nursing and Physician Services Deficiencies

Health

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-05-30

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-05-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-05-30

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 2024-07-12

E · Potential for more than minimal harm 2024-05-30

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 2024-07-12

E · Potential for more than minimal harm 2024-05-30

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 2024-07-12

E · Potential for more than minimal harm 2024-05-30

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-05-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-05-30

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-05-30

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 2024-07-12

D · Potential for more than minimal harm 2024-05-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-05-30

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 2024-07-12

D · Potential for more than minimal harm 2024-05-30

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-03-15

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 2024-04-19

D · Potential for more than minimal harm 2024-03-15

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 2024-04-19

D · Potential for more than minimal harm 2024-03-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-03-15

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-03-15

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-04-19

G · Actual harm 2023-09-21

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-09-21

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-10-12

E · Potential for more than minimal harm 2023-08-02

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-10-12

E · Potential for more than minimal harm 2023-08-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-07-21

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 2023-09-05

D · Potential for more than minimal harm 2023-07-21

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-07-21

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 2023-10-12

D · Potential for more than minimal harm 2023-07-21

F728 · Nursing and Physician Services Deficiencies

Health

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Corrected 2023-09-05

J · Immediate jeopardy 2023-07-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F843 · Administration Deficiencies

Health

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F940 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F946 · Administration Deficiencies

Health

Provide training in compliance and ethics.

Corrected 2023-09-05

F · Potential for more than minimal harm 2023-07-07

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2023-09-05

E · Potential for more than minimal harm 2023-07-07

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 2023-09-05

D · Potential for more than minimal harm 2023-07-07

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 2023-09-05

D · Potential for more than minimal harm 2023-07-07

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 2023-09-05

D · Potential for more than minimal harm 2023-07-07

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-07-07

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-07-07

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 2023-09-05

D · Potential for more than minimal harm 2023-07-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-10-12

D · Potential for more than minimal harm 2023-07-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-10-12

D · Potential for more than minimal harm 2023-07-07

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-04-04

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 2023-05-19

D · Potential for more than minimal harm 2023-04-04

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-19

D · Potential for more than minimal harm 2023-04-04

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-05-19

D · Potential for more than minimal harm 2023-04-04

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2023-05-19

F · Potential for more than minimal harm 2022-09-12

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-10-31

F · Potential for more than minimal harm 2022-09-12

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 2022-10-31

E · Potential for more than minimal harm 2022-09-12

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 2022-10-31

E · Potential for more than minimal harm 2022-09-12

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 2022-10-31