Cycle 1
Health 2024-12-12 · Fire 2024-12-12
28 health deficiencies
Top issue: Resident Rights (8 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Savannah, GA
Thunderbolt Care Center LLC
1-star overall rating with 1-star inspections with Special Focus status with $292,548 in total fines with 28 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
3223 Falligant Avenue, Savannah, GA
(912) 691-2512
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
134
Certified beds
Average residents
15
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peach Health Group
Operator or chain grouping
Approved since
1997-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
12,323
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.45% · Performance 21.84% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.62
Baseline 12.74% · Performance 9.55% · Measure score 3.62 · Achievement 0 · Improvement 3.62
Total nurse turnover
1.33
Baseline 67.31% · Performance 59.52% · Measure score 1.33 · Achievement 1.02 · Improvement 1.33
Adjusted total nurse staffing
0.20
Baseline 2.93 hours · Performance 3.13 hours · Measure score 0.20 · Achievement 0 · Improvement 0.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 90 · Observed rate 11.11% · Lower 95% interval 7.54% |
| Discharge to community | 31.94% |
50.57%
18.6 pts worse
|
Worse than the National Rate · Eligible stays 74 · Observed rate 21.62% · Lower 95% interval 23.58% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 85 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 45.9% |
53.69%
7.8 pts worse
|
Numerator 28 · Denominator 61 |
| Discharge mobility score | 37.7% |
50.94%
13.2 pts worse
|
Numerator 23 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 85 · Adjusted rate 2.49% |
| Healthcare-associated infections requiring hospitalization | 9.55% |
7.12%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 16% · Lower 95% interval 5.96% |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 110 |
| Staff flu vaccination coverage | 32.11% |
42%
9.9 pts worse
|
Numerator 35 · Denominator 109 |
| Discharge function score | 47.54% |
56.45%
8.9 pts worse
|
Numerator 29 · Denominator 61 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 29.82% |
25.2%
4.6 pts better
|
Numerator 17 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.0
1.4 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.3% |
91.2%
9.9 pts worse
|
93.4%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 83.0% · Q3 76.0% · Q4 69.0% · 4Q avg 81.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.9% |
95.0%
7.1 pts worse
|
95.5%
7.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 1.9% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
9.6%
4.7 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.7% · Q3 2.3% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 13.4% |
5.9%
7.5 pts worse
|
5.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 13.5% · Q3 18.3% · Q4 14.8% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
20.7%
3.7 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 18.3% · Q3 16.1% · Q4 11.1% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
21.4%
1.6 pts better
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 20.3% · Q3 21.7% · 4Q avg 19.8% · 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 | 8.5% |
17.9%
9.4 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.8% · Q3 2.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
16.2%
5.7 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 15.7% · Q3 2.3% · Q4 0.0% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 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% |
2.5%
2.5 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 | 12.6% |
16.1%
3.5 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 15.7% · Q3 12.3% · Q4 0.0% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.2%
2.3 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 11.5% · Q3 5.7% · Q4 7.6% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.8% |
80.4%
42.6 pts worse
|
81.7%
43.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.8% · Q2 35.1% · Q3 25.8% · Q4 28.3% · 4Q avg 37.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
12.2%
About the same
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 35.0% |
78.2%
43.2 pts worse
|
79.7%
44.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 35.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
24.2%
6 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 27.4% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-18 · Fire 2023-04-18
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
8 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2021-06-11 · Fire 2021-06-11
16 health deficiencies
Top issue: Resident Rights (5 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
F · Potential for more than minimal harm
2024-12-12
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-20
F · Potential for more than minimal harm
2023-04-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-18
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-18
F · Potential for more than minimal harm
2021-06-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-07-21
F · Potential for more than minimal harm
2021-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-07-21
F · Potential for more than minimal harm
2021-06-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-21
Inspection history
Recent health citations
G · Actual harm
2025-05-23
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.
Not marked corrected
G · Actual harm
2025-05-23
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.
Not marked corrected
F · Potential for more than minimal harm
2025-05-16
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.
Not marked corrected
F · Potential for more than minimal harm
2025-05-16
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.
Not marked corrected
B · Minimal harm
2025-05-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Not marked corrected
L · Immediate jeopardy
2025-04-23
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-05-05
L · Immediate jeopardy
2025-04-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-05
J · Immediate jeopardy
2025-02-14
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 2025-03-27
J · Immediate jeopardy
2025-02-14
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 2025-03-27
J · Immediate jeopardy
2025-02-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-27
J · Immediate jeopardy
2025-02-14
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 2025-03-27
J · Immediate jeopardy
2025-02-14
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-27
J · Immediate jeopardy
2025-02-14
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Not marked corrected
J · Immediate jeopardy
2024-12-12
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 2025-01-20
J · Immediate jeopardy
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-20
J · Immediate jeopardy
2024-12-12
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-05
G · Actual harm
2024-12-12
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 2025-06-08
F · Potential for more than minimal harm
2024-12-12
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 2025-06-08
F · Potential for more than minimal harm
2024-12-12
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 2025-06-08
F · Potential for more than minimal harm
2024-12-12
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 2025-01-20
F · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-12
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 2025-01-20
E · Potential for more than minimal harm
2024-12-12
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 2025-01-20
D · Potential for more than minimal harm
2024-12-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
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 2025-01-20
D · Potential for more than minimal harm
2024-12-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
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 2025-01-20
D · Potential for more than minimal harm
2024-12-12
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 2025-01-20
D · Potential for more than minimal harm
2024-12-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-12
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-01-20
B · Minimal harm
2024-12-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-06-08
G · Actual harm
2023-04-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-18
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 2023-05-18
D · Potential for more than minimal harm
2023-04-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-18
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 2023-05-18
D · Potential for more than minimal harm
2023-04-18
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 2023-05-18
D · Potential for more than minimal harm
2023-04-18
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 2023-05-18
D · Potential for more than minimal harm
2023-04-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-18
E · Potential for more than minimal harm
2021-06-11
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 2021-07-21
E · Potential for more than minimal harm
2021-06-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-06-11
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-06-11
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-06-11
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 2021-08-29
E · Potential for more than minimal harm
2021-06-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-07-21
E · Potential for more than minimal harm
2021-06-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-08-29
D · Potential for more than minimal harm
2021-06-11
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 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-21
Penalties and ownership
What sits behind the stars
$277,362
2024-12-12
Fine
Fine · fine $277,362
Fine
$0
2024-12-12
Payment Denial
Payment Denial · denial start 2025-01-21 · 143 days
143 day denial
$15,186
2023-04-18
Fine
Fine · fine $15,186
Fine
Ownership
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