Hatboro, PA

Willow Grove Post Acute

3-star overall rating with 2-star inspections with 20 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle

3485 Davisville Road, Hatboro, PA

(215) 830-0400

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

109

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Marquis Health Services

Operator or chain grouping

Approved since

1997-01-17

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

81 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

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

1.18

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.56

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.71

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.45

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.74

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.13

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.88

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.14

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.11

CMS adjusted RN staffing hours

Adjusted total hours

3.24

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

62%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,674

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

Performance score

22.90

Composite VBP score used to determine payment impact.

Payment multiplier

0.9830

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.08

Baseline 26.11% · Performance 21.05% · Measure score 5.08 · Achievement 0.83 · Improvement 5.08

Healthcare-associated infections

2.09

Baseline 6.99% · Performance 7.21% · Measure score 2.09 · Achievement 2.09 · Improvement 0

Total nurse turnover

Baseline 49.49% · Performance 64.71% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

Baseline 4.47 hours · Performance 3.65 hours · Measure score 2 · Achievement 2 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.5%	10.72% 1.8 pts worse	No Different than the National Rate · Eligible stays 574 · Observed rate 12.2% · Lower 95% interval 10%
Discharge to community	57.14%	50.57% 6.6 pts better	Better than the National Rate · Eligible stays 646 · Observed rate 53.1% · Lower 95% interval 53.31%
Medicare spending per beneficiary	0.9	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 343 · Denominator 343
Falls with major injury	0.29%	0.77% 0.5 pts better	Numerator 1 · Denominator 343
Discharge self-care score	49.33%	53.69% 4.4 pts worse	Numerator 74 · Denominator 150
Discharge mobility score	53.33%	50.94% 2.4 pts better	Numerator 80 · Denominator 150
Pressure ulcers or injuries, new or worsened	1.75%	2.29% 0.5 pts better	Numerator 6 · Denominator 343 · Adjusted rate 1.85%
Healthcare-associated infections requiring hospitalization	7.21%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 355 · Observed rate 7.32% · Lower 95% interval 5.4%
Staff COVID-19 vaccination coverage	0.85%	8.2% 7.3 pts worse	Numerator 1 · Denominator 118
Staff flu vaccination coverage	40%	42% 2 pts worse	Numerator 44 · Denominator 110
Discharge function score	56.67%	56.45% 0.2 pts better	Numerator 85 · Denominator 150
Transfer of health information to provider	98.47%	95.95% 2.5 pts better	Numerator 129 · Denominator 131
Transfer of health information to patient	99.47%	96.28% 3.2 pts better	Numerator 186 · Denominator 187
Resident COVID-19 vaccinations up to date	5.88%	25.2% 19.3 pts worse	Numerator 10 · Denominator 170

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	61.2%	86.9% 25.7 pts worse	93.4% 32.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 34.8% · Q3 78.9% · Q4 69.2% · 4Q avg 61.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	88.5%	93.5% 5 pts worse	95.5% 7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 88.5%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.2% 2.4 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	12.5%	6.5% 6 pts worse	11.4% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 11.1% · Q4 17.9% · 4Q avg 12.5%
Percentage of long-stay residents who lose too much weight	6.4%	6.5% 0.1 pts better	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 20.0% · Q3 3.3% · Q4 2.3% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.3%	19.9% 3.4 pts worse	19.6% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 21.7% · Q3 23.5% · Q4 25.5% · 4Q avg 23.3%
Percentage of long-stay residents who received an antipsychotic medication	27.7%	18.7% 9 pts worse	16.7% 11 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 30.0% · Q4 29.4% · 4Q avg 27.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	12.2%	19.6% 7.4 pts better	16.3% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 12.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.1%	18.3% 2.2 pts better	14.9% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 18.2% · Q4 18.6% · 4Q avg 16.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · 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	0.8%	1.7% 0.9 pts better	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.2%	26.4% 1.2 pts better	19.8% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 24.3% · Q3 27.4% · Q4 23.4% · 4Q avg 25.2%
Percentage of long-stay residents with pressure ulcers	10.0%	5.3% 4.7 pts worse	5.1% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 10.1% · Q3 12.0% · Q4 6.3% · 4Q avg 10.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	37.9%	68.9% 31 pts worse	81.7% 43.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 39.1% · Q3 55.6% · Q4 51.4% · 4Q avg 37.9%
Percentage of short-stay residents who had an outpatient emergency department visit	4.9%	9.8% 4.9 pts better	12.0% 7.1 pts better	Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.9% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.3%	1.5% 0.2 pts better	1.6% 0.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.5% · Q4 0.7% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	51.2%	68.7% 17.5 pts worse	79.7% 28.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 51.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.4%	23.1% 2.7 pts better	23.9% 3.5 pts better	Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 21.1% · Expected 24.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-16 · Fire 2025-05-16

20 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

15 fire-safety deficiencies

Top issue: Emergency Preparedness (7 deficiencies)

Cycle 2 Health 2024-08-15 · Fire 2024-08-15

26 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-11-08 · Fire 2023-11-08

14 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-16

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-07-14

F · Potential for more than minimal harm 2025-05-16

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-14

F · Potential for more than minimal harm 2025-05-16

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-05-16

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-05-16

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-05-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-05-16

K521 · Services Deficiencies

Fire Safety

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

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-05-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E30 · Emergency Preparedness Deficiencies

Fire Safety

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

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-07-14

C · Minimal harm 2025-05-16

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-07-14

E · Potential for more than minimal harm 2024-08-15

K233 · Egress Deficiencies

Fire Safety

Install resident room doors of proper design and width.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

K906 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas cylinders are properly stored.

Corrected 2024-10-02

C · Minimal harm 2024-08-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-02

F · Potential for more than minimal harm 2024-01-19

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-03-02

C · Minimal harm 2024-01-19

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-03-02

F · Potential for more than minimal harm 2023-11-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-01-19

F · Potential for more than minimal harm 2023-11-08

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-08

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-08

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-08

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-08

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-08

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-01-19

C · Minimal harm 2023-11-08

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-01-19

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-30

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 2026-01-29

D · Potential for more than minimal harm 2025-12-30

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-29

E · Potential for more than minimal harm 2025-12-01

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 2026-01-06

D · Potential for more than minimal harm 2025-12-01

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2026-01-06

E · Potential for more than minimal harm 2025-05-16

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

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 2025-07-08

E · Potential for more than minimal harm 2025-05-16

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-05-16

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

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 2025-07-08

D · Potential for more than minimal harm 2025-05-16

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 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F710 · Nursing and Physician Services Deficiencies

Health

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-07-08

D · Potential for more than minimal harm 2025-05-16

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-07-08

E · Potential for more than minimal harm 2024-12-09

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-01-21

D · Potential for more than minimal harm 2024-12-09

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-01-21

E · Potential for more than minimal harm 2024-09-09

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 2024-10-16

E · Potential for more than minimal harm 2024-09-09

F924 · Environmental Deficiencies

Health

Put firmly secured handrails on each side of hallways.

Corrected 2024-10-16

D · Potential for more than minimal harm 2024-09-09

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-10-16

D · Potential for more than minimal harm 2024-09-09

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 2024-10-16

E · Potential for more than minimal harm 2024-08-15

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-02

E · Potential for more than minimal harm 2024-08-15

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

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 2024-10-02

D · Potential for more than minimal harm 2024-08-15

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 2024-10-02

D · Potential for more than minimal harm 2024-08-15

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 2024-10-02

D · Potential for more than minimal harm 2024-08-15

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 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-15

F940 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-06-10

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 2024-07-30

D · Potential for more than minimal harm 2024-05-07

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2024-07-06

D · Potential for more than minimal harm 2024-04-27

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-24

D · Potential for more than minimal harm 2024-03-06

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-04-23