Cycle 1
Health 2024-12-05 · Fire 2024-12-05
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Sparks, NV
Wingfield Skilled Nursing And Rehabilitation Cente
2-star overall rating with 3-star inspections with $75,670 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2350 Wingfield Hills Rd, Sparks, NV
(775) 335-8275
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-03-03
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
0.56
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,764
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 15.77% · Performance 22.72% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.97% · Performance 7.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.38
Baseline 82.57% · Performance 42.86% · Measure score 6.38 · Achievement 5.09 · Improvement 6.38
Adjusted total nurse staffing
1.29
Baseline 3.66 hours · Performance 3.45 hours · Measure score 1.29 · Achievement 1.29 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 276 · Observed rate 9.78% · Lower 95% interval 8.04% |
| Discharge to community | 53.48% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 291 · Observed rate 48.8% · Lower 95% interval 45.71% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 86.64% |
95.27%
8.6 pts worse
|
Numerator 201 · Denominator 232 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 232 |
| Discharge self-care score | 48.72% |
53.69%
5 pts worse
|
Numerator 76 · Denominator 156 |
| Discharge mobility score | 48.08% |
50.94%
2.9 pts worse
|
Numerator 75 · Denominator 156 |
| Pressure ulcers or injuries, new or worsened | 5.63% |
2.29%
3.3 pts worse
|
Numerator 13 · Denominator 231 · Adjusted rate 5.27% |
| Healthcare-associated infections requiring hospitalization | 7.93% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 213 · Observed rate 7.98% · Lower 95% interval 5.36% |
| Staff COVID-19 vaccination coverage | 9.74% |
8.2%
1.5 pts better
|
Numerator 15 · Denominator 154 |
| Staff flu vaccination coverage | 30% |
42%
12 pts worse
|
Numerator 66 · Denominator 220 |
| Discharge function score | 49.36% |
56.45%
7.1 pts worse
|
Numerator 77 · Denominator 156 |
| Transfer of health information to provider | 89.66% |
95.95%
6.3 pts worse
|
Numerator 52 · Denominator 58 |
| Transfer of health information to patient | 75.54% |
96.28%
20.7 pts worse
|
Numerator 105 · Denominator 139 |
| Resident COVID-19 vaccinations up to date | 22.02% |
25.2%
3.2 pts worse
|
Numerator 24 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.5%
7.9 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
89.6%
8.2 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
2.3%
2.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.8% · Q3 4.9% · Q4 4.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
4.9%
2.1 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.8% · Q3 1.3% · Q4 1.2% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.6%
2.2 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.8% · Q3 4.1% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
22.2%
0.5 pts better
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 19.2% · Q3 21.3% · Q4 19.0% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
18.5%
0.1 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.0% · Q3 20.0% · Q4 21.0% · 4Q avg 18.6% · 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 | 31.1% |
19.1%
12 pts worse
|
16.3%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.0% · Q2 41.8% · Q3 26.3% · Q4 11.2% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
14.2%
4.6 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 26.9% · Q3 14.5% · Q4 3.9% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.8%
1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.8%
1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 1.2% · Q4 2.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
16.5%
0.9 pts worse
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 18.1% · Q3 19.3% · Q4 10.0% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.5%
1.2 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.3% · Q3 7.9% · Q4 5.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
84.1%
12.8 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 96.9% · Q3 97.5% · Q4 97.6% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
9.8%
6.2 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 16.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.6%
0.9 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.7% · Q3 1.9% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
80.7%
10.3 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
23.4%
5.2 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 27.4% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
31 health deficiencies
Top issue: Resident Rights (6 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-03
D · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-14
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-09
E · Potential for more than minimal harm
2022-11-18
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
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 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-02-27
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 2024-04-01
D · Potential for more than minimal harm
2024-02-27
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 2024-04-01
D · Potential for more than minimal harm
2024-02-27
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 2024-04-01
B · Minimal harm
2024-02-27
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 2024-04-01
G · Actual harm
2023-12-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-12-14
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 2024-01-26
D · Potential for more than minimal harm
2023-12-14
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 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
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 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
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 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
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 2024-01-26
D · Potential for more than minimal harm
2023-12-14
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-14
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 2024-01-26
C · Minimal harm
2023-12-14
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-01-26
G · Actual harm
2023-11-15
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 2023-11-15
G · Actual harm
2023-11-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-11-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-15
F · Potential for more than minimal harm
2022-11-18
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 2023-01-10
E · Potential for more than minimal harm
2022-11-18
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 2023-01-10
E · Potential for more than minimal harm
2022-11-18
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 2023-01-10
E · Potential for more than minimal harm
2022-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
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 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-18
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-01-10
Penalties and ownership
What sits behind the stars
$75,670
2023-12-14
Fine
Fine · fine $75,670
Fine
Ownership
Gray Estate Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Gray, Zachary
5% Or Greater Indirect Ownership Interest · Individual
Asl Realty LLC
5% Or Greater Mortgage Interest · Organization
Gray Estate Holdings LLC
5% Or Greater Mortgage Interest · Organization
Gray, Chelsey
Operational/Managerial Control · Individual
Gray, Zachary
Operational/Managerial Control · Individual
Gray, Zachary
Corporate Officer · Individual
Gray, Zachary
5% Or Greater Mortgage Interest · Individual
Ilyas, Irtqa
Operational/Managerial Control · Individual
Lebowitz, Andrew
5% Or Greater Mortgage Interest · Individual
Modina, Kaitlyn
Operational/Managerial Control · Individual
Nadora, Marie
Operational/Managerial Control · Individual
Nasrawy, Joseph
Operational/Managerial Control · Individual
Revive Health Senior Care Management LLC
Operational/Managerial Control · Organization
Wingfield Hills Rd. LLC
5% Or Greater Mortgage Interest · Organization
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