Cycle 1
Health 2025-01-09 · Fire 2025-01-09
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
North Royalton, OH
The Pavilion Rehabilitation And Nursing Center
2-star overall rating with 1-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
13900 Bennett Road, North Royalton, OH
(440) 237-7966
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Northwood Healthcare Group
Operator or chain grouping
Approved since
1998-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 1 staffing / 5 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
0.27
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,042
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
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
2.73
Baseline 94.03% · Performance 71.70% · Measure score 2.73 · Achievement 0 · Improvement 2.73
Adjusted total nurse staffing
3.46
Baseline 3.02 hours · Performance 4.06 hours · Measure score 3.46 · Achievement 3.46 · Improvement 3.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 70 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 87 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · 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 | 75.0% |
92.4%
17.4 pts worse
|
93.4%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 85.7% · Q3 45.2% · Q4 92.5% · 4Q avg 75.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.2% |
94.5%
4.3 pts worse
|
95.5%
5.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long 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 long-stay residents who have depressive symptoms | 10.9% |
26.1%
15.2 pts better
|
11.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 2.9% · Q3 5.0% · Q4 28.6% · 4Q avg 10.9% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
6.2%
4.1 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 2.4% · Q4 2.6% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 43.8% |
25.4%
18.4 pts worse
|
19.6%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 52.9% · Q3 46.3% · Q4 34.2% · 4Q avg 43.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
11.5%
4.2 pts worse
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 20.8% · Q4 13.0% · 4Q avg 15.7% · 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 | 1.1% |
7.7%
6.6 pts better
|
16.3%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.4% |
6.2%
4.8 pts better
|
14.9%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 12.2% |
21.7%
9.5 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 13.9% · Q3 8.3% · Q4 13.3% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
3.7%
4.9 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.9% · Q3 8.4% · Q4 4.1% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.1% |
78.1%
31 pts worse
|
81.7%
34.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 56.9% · Q3 44.9% · Q4 57.1% · 4Q avg 47.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.2%
2 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.3% |
75.6%
30.3 pts worse
|
79.7%
34.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-24 · Fire 2022-10-24
33 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-10-31 · Fire 2019-10-31
22 health deficiencies
Top issue: Resident Rights (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-29
F · Potential for more than minimal harm
2022-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-24
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 2022-11-18
F · Potential for more than minimal harm
2019-10-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
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 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-29
F · Potential for more than minimal harm
2019-10-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-11-29
E · Potential for more than minimal harm
2019-10-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-11-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-19
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 2025-01-27
D · Potential for more than minimal harm
2025-02-19
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 2025-03-10
F · Potential for more than minimal harm
2025-01-09
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 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
D · Potential for more than minimal harm
2025-01-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
D · Potential for more than minimal harm
2025-01-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
F · Potential for more than minimal harm
2024-11-26
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-08-19
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 2024-08-23
F · Potential for more than minimal harm
2024-06-26
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 2024-07-12
F · Potential for more than minimal harm
2024-06-26
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 2024-07-12
F · Potential for more than minimal harm
2024-06-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-26
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 2024-07-12
D · Potential for more than minimal harm
2024-06-26
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-15
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 2024-06-03
F · Potential for more than minimal harm
2024-05-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-03
C · Minimal harm
2024-05-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-03-22
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 2024-04-05
D · Potential for more than minimal harm
2024-03-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-03-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-21
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-21
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 2023-04-13
F · Potential for more than minimal harm
2023-03-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-21
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 2023-04-13
E · Potential for more than minimal harm
2023-03-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-21
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 2023-04-13
E · Potential for more than minimal harm
2023-03-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-21
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 2023-04-13
D · Potential for more than minimal harm
2023-03-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-13
C · Minimal harm
2023-03-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-04-13
C · Minimal harm
2023-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-13
K · Immediate jeopardy
2022-10-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-18
J · Immediate jeopardy
2022-10-24
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 2022-11-18
E · Potential for more than minimal harm
2022-10-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
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 2022-11-18
D · Potential for more than minimal harm
2022-10-24
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 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
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 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
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 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
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 2022-11-18
D · Potential for more than minimal harm
2022-10-24
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 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-11-18
F · Potential for more than minimal harm
2019-10-31
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2019-11-29
E · Potential for more than minimal harm
2019-10-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-11-29
E · Potential for more than minimal harm
2019-10-31
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.
Corrected 2019-11-29
E · Potential for more than minimal harm
2019-10-31
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-11-29
E · Potential for more than minimal harm
2019-10-31
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 2019-11-29
D · Potential for more than minimal harm
2019-10-31
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 2019-11-29
D · Potential for more than minimal harm
2019-10-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-11-29
D · Potential for more than minimal harm
2019-10-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-29
D · Potential for more than minimal harm
2019-10-31
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 2019-11-29
Penalties and ownership
What sits behind the stars
Ownership
Braunstein Bears 2016 Trust
5% Or Greater Indirect Ownership Interest · Organization
Northwood Healthcare Member LLC
5% Or Greater Indirect Ownership Interest · Organization
El-Northwood LLC
5% Or Greater Indirect Ownership Interest · Organization
Lahasky, Ephram
5% Or Greater Indirect Ownership Interest · Individual
Feuer, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Katz, Larry
5% Or Greater Indirect Ownership Interest · Individual
Braunstein, Barry
Corporate Officer · Individual
Dreifus, Ethan
5% Or Greater Direct Ownership Interest · Individual
Feuer, Samuel
Corporate Officer · Individual
Katz, Larry
Corporate Officer · Individual
Lahasky, Ephram
Corporate Officer · Individual
Leshkowitz, Eli
5% Or Greater Indirect Ownership Interest · Individual
Leshkowitz, Eli
Corporate Officer · Individual
Northwood Healthcare Group LLC
Operational/Managerial Control · Organization
Northwood Healthcare Managing Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Northwood Healthcare Operating Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Strubel, Kim
W-2 Managing Employee · Individual
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#3
Diplomat Healthcare
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2-star overall rating with 1-star inspections with $11,213 in total fines with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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