Cincinnati, OH

Wellspring Health Center

2-star overall rating with 2-star inspections with $122,030 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

8000 Evergreen Ridge Drive, Cincinnati, OH

(513) 948-2308

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1990-10-31

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.84

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.06

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.39

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.28

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.89

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.79

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.88

CMS adjusted RN staffing hours

Adjusted total hours

4.51

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

70%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,164

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

Performance score

21.27

Composite VBP score used to determine payment impact.

Payment multiplier

0.9826

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.98% · Performance 23.32% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.44

Baseline 5.10% · Performance 7.40% · Measure score 1.44 · Achievement 1.44 · Improvement 0

Total nurse turnover

3.12

Baseline 55.36% · Performance 50.91% · Measure score 3.12 · Achievement 3.12 · Improvement 0.96

Adjusted total nurse staffing

3.94

Baseline 4 hours · Performance 4.2 hours · Measure score 3.94 · Achievement 3.94 · Improvement 0.63

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.37%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 137 · Observed rate 6.57% · Lower 95% interval 6.59%
Discharge to community	66.25%	50.57% 15.7 pts better	Better than the National Rate · Eligible stays 127 · Observed rate 61.42% · Lower 95% interval 56.93%
Medicare spending per beneficiary	0.82	1.02 0.2 pts better
Drug regimen review with follow-up	98.85%	95.27% 3.6 pts better	Numerator 86 · Denominator 87
Falls with major injury	2.3%	0.77% 1.5 pts worse	Numerator 2 · Denominator 87
Discharge self-care score	40.98%	53.69% 12.7 pts worse	Numerator 25 · Denominator 61
Discharge mobility score	22.95%	50.94% 28 pts worse	Numerator 14 · Denominator 61
Pressure ulcers or injuries, new or worsened	2.3%	2.29% About the same	Numerator 2 · Denominator 87 · Adjusted rate 2.53%
Healthcare-associated infections requiring hospitalization	7.4%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 78 · Observed rate 7.69% · Lower 95% interval 4.47%
Staff COVID-19 vaccination coverage	3.25%	8.2% 4.9 pts worse	Numerator 4 · Denominator 123
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	32.79%	56.45% 23.7 pts worse	Numerator 20 · Denominator 61
Transfer of health information to provider	97.1%	95.95% 1.1 pts better	Numerator 67 · Denominator 69
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	27.5%	25.2% 2.3 pts better	Numerator 11 · Denominator 40

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.4% 7.6 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	100.0%	94.5% 5.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
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	2.4%	26.1% 23.7 pts better	11.4% 9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.8% · Q4 4.3% · 4Q avg 2.4%
Percentage of long-stay residents who lose too much weight	8.0%	6.2% 1.8 pts worse	5.4% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · 4Q avg 8.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.3%	25.4% 15.1 pts better	19.6% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q4 10.0% · 4Q avg 10.3%
Percentage of long-stay residents who received an antipsychotic medication	14.3%	11.5% 2.8 pts worse	16.7% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · 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 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 0.0% · Q4 5.0% · 4Q avg 7.7% · 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% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.9%	0.5% 1.4 pts worse	1.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.3%	21.7% 0.6 pts worse	19.8% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 20.5% · Q3 53.5% · Q4 0.0% · 4Q avg 22.3%
Percentage of long-stay residents with pressure ulcers	9.4%	3.7% 5.7 pts worse	5.1% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 9.8% · Q3 11.9% · Q4 4.8% · 4Q avg 9.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.8%	78.1% 16.7 pts better	81.7% 13.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 95.7% · Q3 97.4% · Q4 91.7% · 4Q avg 94.8%
Percentage of short-stay residents who had an outpatient emergency department visit	15.7%	12.5% 3.2 pts worse	12.0% 3.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 15.4% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.2% About the same	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.3%	75.6% 13.7 pts better	79.7% 9.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.6%	25.1% 1.5 pts better	23.9% 0.3 pts better	Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 21.5% · Expected 21.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2022-08-30 · Fire 2022-08-30

8 health deficiencies

Top issue: Resident Rights (4 deficiencies)

11 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2019-04-04 · Fire 2019-04-04

16 health deficiencies

Top issue: Resident Rights (5 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2018-03-08 · Fire 2018-03-08

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

22 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2022-08-30

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K521 · Services Deficiencies

Fire Safety

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

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2022-10-20

F · Potential for more than minimal harm 2022-08-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-10-20

E · Potential for more than minimal harm 2022-08-30

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 2022-10-20

E · Potential for more than minimal harm 2022-08-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-10-20

E · Potential for more than minimal harm 2022-08-30

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-10-20

F · Potential for more than minimal harm 2019-04-04

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

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 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K521 · Services Deficiencies

Fire Safety

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

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-05-17

E · Potential for more than minimal harm 2019-04-04

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2019-05-17

F · Potential for more than minimal harm 2018-03-08

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K521 · Services Deficiencies

Fire Safety

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

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2018-04-09

F · Potential for more than minimal harm 2018-03-08

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 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2018-04-09

E · Potential for more than minimal harm 2018-03-08

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 2018-04-09

E · Potential for more than minimal harm 2018-03-08

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 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2018-04-09

E · Potential for more than minimal harm 2018-03-08

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 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2018-04-09

E · Potential for more than minimal harm 2018-03-08

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 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2018-04-09

E · Potential for more than minimal harm 2018-03-08

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2018-04-09

Inspection history

Recent health citations

J · Immediate jeopardy 2025-04-28

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 2025-05-12

D · Potential for more than minimal harm 2025-04-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-12

E · Potential for more than minimal harm 2025-02-18

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 2025-03-20

D · Potential for more than minimal harm 2025-02-18

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-18

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 2025-03-20

D · Potential for more than minimal harm 2024-02-21

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 2024-03-22

D · Potential for more than minimal harm 2024-02-21

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-22

F · Potential for more than minimal harm 2022-08-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-20

E · Potential for more than minimal harm 2022-08-30

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2022-10-20

D · Potential for more than minimal harm 2022-08-30

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 2022-10-20

D · Potential for more than minimal harm 2022-08-30

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2022-10-20

D · Potential for more than minimal harm 2022-08-30

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 2022-10-20

D · Potential for more than minimal harm 2022-08-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-10-20

F · Potential for more than minimal harm 2019-04-04

F761 · Pharmacy Service Deficiencies

Health

Corrected 2019-05-17

F · Potential for more than minimal harm 2019-04-04

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 2019-05-17

E · Potential for more than minimal harm 2019-04-04

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-05-17

E · Potential for more than minimal harm 2019-04-04

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 2019-05-17

D · Potential for more than minimal harm 2019-04-04

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 2019-05-17

D · Potential for more than minimal harm 2019-04-04

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2019-05-17

D · Potential for more than minimal harm 2019-04-04

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 2019-05-17

D · Potential for more than minimal harm 2019-04-04

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 2019-05-17

D · Potential for more than minimal harm 2019-04-04

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 2019-05-17

D · Potential for more than minimal harm 2019-04-04

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2019-05-17

D · Potential for more than minimal harm 2019-04-04

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 2019-05-17

D · Potential for more than minimal harm 2019-04-04

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2019-05-17

D · Potential for more than minimal harm 2019-04-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-05-17

F · Potential for more than minimal harm 2018-03-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-04-09

D · Potential for more than minimal harm 2018-03-08

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2018-04-09

D · Potential for more than minimal harm 2018-03-08

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2018-04-09

D · Potential for more than minimal harm 2018-03-08

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 2018-04-09

D · Potential for more than minimal harm 2018-03-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2018-04-09

D · Potential for more than minimal harm 2018-03-08

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 2018-04-09

D · Potential for more than minimal harm 2018-03-08

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 2018-04-09

D · Potential for more than minimal harm 2018-03-08

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2018-04-09

Penalties and ownership

What sits behind the stars

$110,468 2025-04-28

Fine

Fine · fine $110,468

Fine

$2,823 2023-05-23

Fine

Fine · fine $2,823

Fine

$2,447 2023-05-15

Fine

Fine · fine $2,447

Fine

$2,098 2023-05-08

Fine

Fine · fine $2,098

Fine

$4,194 2023-04-17

Fine

Fine · fine $4,194

Fine

Ownership

Ccrc Ops Mb1-T LLC

5% Or Greater Direct Ownership Interest · Organization

100% 4 facilities 2014-12-03

Aurora Vitality LLC