Cycle 1
Health 2024-10-29 · Fire 2024-10-29
13 health deficiencies
Top issue: Infection Control (2 deficiencies)
28 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Ashland, MA
Waterview Lodge LLC, Rehabilitation & Healthcare
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 28 fire-safety deficiencies in the latest cycle
250 West Union Street, Ashland, MA
(508) 848-4220
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
15%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,163
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.01% · Performance 23.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.10% · Performance 8.80% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.03
Baseline 35.29% · Performance 26.76% · Measure score 9.03 · Achievement 9.03 · Improvement 7.67
Adjusted total nurse staffing
3.20
Baseline 2.92 hours · Performance 3.98 hours · Measure score 3.20 · Achievement 3.16 · Improvement 3.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 10.53% · Lower 95% interval 7.63% |
| Discharge to community | 48.82% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 40.98% · Lower 95% interval 38.6% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 65 · Denominator 65 |
| Falls with major injury | 4.62% |
0.77%
3.9 pts worse
|
Numerator 3 · Denominator 65 |
| Discharge self-care score | 24.39% |
53.69%
29.3 pts worse
|
Numerator 10 · Denominator 41 |
| Discharge mobility score | 53.66% |
50.94%
2.7 pts better
|
Numerator 22 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 65 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.8% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 11.43% · Lower 95% interval 5.25% |
| Staff COVID-19 vaccination coverage | 55% |
8.2%
46.8 pts better
|
Numerator 55 · Denominator 100 |
| Staff flu vaccination coverage | 74% |
42%
32 pts better
|
Numerator 74 · Denominator 100 |
| Discharge function score | 58.54% |
56.45%
2.1 pts better
|
Numerator 24 · Denominator 41 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 52.63% |
25.2%
27.4 pts better
|
Numerator 20 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
1.9
1.5 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.8%
2.9 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.5%
1.2 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.9% · Q3 7.5% · Q4 1.3% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
12.0%
9 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.5% · Q3 4.1% · Q4 1.4% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.2%
0.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.6% · Q3 6.5% · Q4 4.2% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
19.2%
7.2 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.1% · Q3 13.9% · Q4 10.8% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 44.6% |
22.5%
22.1 pts worse
|
16.7%
27.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 44.7% · Q3 46.7% · Q4 42.9% · 4Q avg 44.6% · 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 | 4.6% |
17.7%
13.1 pts better
|
16.3%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.0% · Q3 2.1% · Q4 6.7% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
17.6%
10.9 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 11.1% · Q3 9.7% · Q4 4.5% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
1.0%
2.3 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.0% · Q3 3.8% · Q4 1.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.0%
1.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.9% · Q3 2.6% · Q4 5.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.9% |
21.7%
19.8 pts better
|
19.8%
17.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.7% · Q3 1.2% · Q4 2.5% · 4Q avg 1.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.6%
0.9 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.1% · Q3 6.4% · Q4 5.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
77.1%
21.8 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.9% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
11.8%
6 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 5.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.3%
3.4 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.0% |
77.7%
32.7 pts worse
|
79.7%
34.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
25.8%
0.4 pts better
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 26.1% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-14 · Fire 2023-08-14
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-01-18 · Fire 2022-01-18
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-29
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-29
F · Potential for more than minimal harm
2024-10-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
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 2025-01-07
F · Potential for more than minimal harm
2024-10-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-10-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-10-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-10-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-10-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-10-29
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-07
E · Potential for more than minimal harm
2024-10-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-10-29
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-10-29
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-10-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-10-29
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-10-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-10-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-10-29
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 2025-01-07
D · Potential for more than minimal harm
2024-10-29
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-10-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-10-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-10-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-10-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-07
D · Potential for more than minimal harm
2023-08-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-29
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-12-08
F · Potential for more than minimal harm
2024-10-29
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 2024-11-22
E · Potential for more than minimal harm
2024-10-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-08
E · Potential for more than minimal harm
2024-10-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-08
D · Potential for more than minimal harm
2024-10-29
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 2024-12-08
D · Potential for more than minimal harm
2024-10-29
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 2024-12-08
D · Potential for more than minimal harm
2024-10-29
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 2024-12-08
D · Potential for more than minimal harm
2024-10-29
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 2024-12-08
D · Potential for more than minimal harm
2024-10-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-08
D · Potential for more than minimal harm
2024-10-29
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 2024-12-08
D · Potential for more than minimal harm
2024-10-29
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 2024-12-08
D · Potential for more than minimal harm
2024-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
B · Minimal harm
2024-10-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-08
F · Potential for more than minimal harm
2023-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-08-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-08-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-14
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 2023-09-27
D · Potential for more than minimal harm
2023-08-14
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 2023-09-27
D · Potential for more than minimal harm
2023-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-14
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 2023-09-27
D · Potential for more than minimal harm
2023-08-14
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-14
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 2023-09-27
C · Minimal harm
2023-08-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-27
F · Potential for more than minimal harm
2022-01-18
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-03-02
F · Potential for more than minimal harm
2022-01-18
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 2022-03-02
E · Potential for more than minimal harm
2022-01-18
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 2022-03-02
E · Potential for more than minimal harm
2022-01-18
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 2022-03-02
E · Potential for more than minimal harm
2022-01-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-18
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 2022-03-02
D · Potential for more than minimal harm
2022-01-18
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 2022-03-02
D · Potential for more than minimal harm
2022-01-18
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 2022-03-02
D · Potential for more than minimal harm
2022-01-18
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-18
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-02
Penalties and ownership
What sits behind the stars
Ownership
Desai, Indira
5% Or Greater Direct Ownership Interest · Individual
Desai, Indira
Operational/Managerial Control · Individual
Desai, Indira
Corporate Officer · Individual
Desai, Indira
W-2 Managing Employee · Individual
Waterview Lodge LLC
5% Or Greater Direct Ownership Interest · Organization
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