Cycle 1
Health 2025-05-15 · Fire 2025-05-15
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Perrysburg, OH
Three Meadows Post Acute
2-star overall rating with 1-star inspections with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
10540 Fremont Pike Rd, Perrysburg, OH
(419) 874-3578
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Health Services
Operator or chain grouping
Approved since
1980-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 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
0.55
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,112
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
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
2.76
Baseline 52.17% · Performance 52.38% · Measure score 2.76 · Achievement 2.76 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.61 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 7.04% |
| Discharge to community | 54.76% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 51.11% · Lower 95% interval 37.98% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · 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 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.42% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 124 |
| Staff flu vaccination coverage | 10.43% |
42%
31.6 pts worse
|
Numerator 29 · Denominator 278 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · 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 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · 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 | 91.0% |
92.4%
1.4 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 92.9% · Q3 90.0% · Q4 85.3% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.1% |
94.5%
13.4 pts worse
|
95.5%
14.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.7% |
26.1%
3.4 pts better
|
11.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 6.8% · Q3 9.7% · Q4 53.5% · 4Q avg 22.7% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.2%
2 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 6.5% · Q3 7.9% · Q4 4.4% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.5% |
25.4%
9.1 pts worse
|
19.6%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 33.9% · Q3 37.5% · Q4 36.8% · 4Q avg 34.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
11.5%
2.5 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 8.3% · Q3 6.2% · Q4 7.3% · 4Q avg 9.0% · 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 | 13.3% |
7.7%
5.6 pts worse
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q4 7.2% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
6.2%
1.5 pts worse
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.3% · Q3 5.2% · Q4 6.1% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.2%
1.1 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 2.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.5%
0.5 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
21.7%
6.9 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 45.6% · Q3 14.3% · Q4 25.6% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
3.7%
0.8 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 4.7% · Q3 2.4% · Q4 3.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.2% |
78.1%
4.1 pts better
|
81.7%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 87.5% · Q3 76.1% · Q4 69.6% · 4Q avg 82.2% |
| 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 · 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 | 69.5% |
75.6%
6.1 pts worse
|
79.7%
10.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-05 · Fire 2022-12-05
23 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-01-09 · Fire 2020-01-09
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-15
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 2025-06-20
F · Potential for more than minimal harm
2025-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-15
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 2025-06-20
E · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-20
F · Potential for more than minimal harm
2022-12-05
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 2023-01-13
F · Potential for more than minimal harm
2022-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-13
F · Potential for more than minimal harm
2022-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-13
F · Potential for more than minimal harm
2022-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-05
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 2023-01-13
C · Minimal harm
2022-12-05
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-01-13
F · Potential for more than minimal harm
2020-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-28
F · Potential for more than minimal harm
2020-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-02-28
F · Potential for more than minimal harm
2020-01-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2020-02-28
E · Potential for more than minimal harm
2020-01-09
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 2020-02-28
E · Potential for more than minimal harm
2020-01-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-02-28
C · Minimal harm
2020-01-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-02-28
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-23
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 2025-12-24
D · Potential for more than minimal harm
2025-12-23
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 2025-12-24
D · Potential for more than minimal harm
2025-12-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-24
G · Actual harm
2025-05-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
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 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-15
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 2025-06-20
D · Potential for more than minimal harm
2025-05-15
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 2025-06-20
D · Potential for more than minimal harm
2024-09-04
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 2024-09-05
D · Potential for more than minimal harm
2024-06-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-04-02
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 2024-04-12
D · Potential for more than minimal harm
2024-04-02
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 2024-04-12
D · Potential for more than minimal harm
2024-04-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-02-08
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 2024-02-15
D · Potential for more than minimal harm
2024-02-08
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 2024-02-15
D · Potential for more than minimal harm
2023-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-06-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-06-09
F · Potential for more than minimal harm
2022-12-05
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 2023-01-13
F · Potential for more than minimal harm
2022-12-05
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 2023-01-13
E · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
D · Potential for more than minimal harm
2022-12-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-05
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 2023-01-13
E · Potential for more than minimal harm
2020-01-09
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 2020-02-28
E · Potential for more than minimal harm
2020-01-09
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 2020-02-28
E · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-28
Penalties and ownership
What sits behind the stars
$0
2025-05-15
Payment Denial
Payment Denial · denial start 2025-06-12 · 8 days
8 day denial
Ownership
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