Cycle 1
Health 2025-07-24 · Fire 2025-07-24
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Woodbury, MN
Woodbury Health Care Center
1-star overall rating with 1-star inspections with $26,685 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
7012 Lake Road, Woodbury, MN
(651) 735-6000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespark
Operator or chain grouping
Approved since
1981-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 1 overall / 1 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,669
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.27
Baseline 19.43% · Performance 20.38% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Healthcare-associated infections
0
Baseline 4.07% · Performance 9.63% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.46
Baseline 3.52 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 0.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 8.72% · Lower 95% interval 7.13% |
| Discharge to community | 62.07% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 231 · Observed rate 54.11% · Lower 95% interval 53.25% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.06% |
95.27%
3.8 pts better
|
Numerator 105 · Denominator 106 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 106 |
| Discharge self-care score | 39.71% |
53.69%
14 pts worse
|
Numerator 27 · Denominator 68 |
| Discharge mobility score | 38.24% |
50.94%
12.7 pts worse
|
Numerator 26 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 5.66% |
2.29%
3.4 pts worse
|
Numerator 6 · Denominator 106 · Adjusted rate 5.35% |
| Healthcare-associated infections requiring hospitalization | 9.63% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 135 · Observed rate 12.59% · Lower 95% interval 6.68% |
| Staff COVID-19 vaccination coverage | 4.09% |
8.2%
4.1 pts worse
|
Numerator 9 · Denominator 220 |
| Staff flu vaccination coverage | 32.24% |
42%
9.8 pts worse
|
Numerator 79 · Denominator 245 |
| Discharge function score | 48.53% |
56.45%
7.9 pts worse
|
Numerator 33 · Denominator 68 |
| Transfer of health information to provider | 98.08% |
95.95%
2.1 pts better
|
Numerator 51 · Denominator 52 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 33.96% |
25.2%
8.8 pts better
|
Numerator 18 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.2 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.4 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 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 | 98.8% |
96.1%
2.7 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.9%
2.3 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
4.3%
0.4 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 8.8% · Q3 1.4% · Q4 2.8% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.1%
0.8 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.4% · Q3 10.1% · Q4 1.4% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
12.4%
3.2 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 14.3% · Q3 7.1% · Q4 5.6% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
17.5%
1.2 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 11.4% · Q3 16.4% · Q4 18.0% · 4Q avg 16.3% · 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 ability to walk independently worsened | 26.3% |
22.5%
3.8 pts worse
|
16.3%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 8.0% · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
18.6%
1.8 pts better
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 22.0% · Q3 14.1% · Q4 9.2% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.3%
1.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
24.8%
5 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 33.3% · Q3 10.2% · Q4 40.5% · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.4%
0.1 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.3% · Q3 5.7% · Q4 3.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
88.6%
10.5 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 99.6% · Q3 99.1% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
14.0%
9.2 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.9%
0.8 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.2% · Q3 0.6% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
82.7%
2.5 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
23.1%
6 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 29.8% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Cycle 3
Health 2023-08-10 · Fire 2023-08-10
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 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
2025-07-24
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 2025-10-01
F · Potential for more than minimal harm
2025-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-01
F · Potential for more than minimal harm
2025-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-01
F · Potential for more than minimal harm
2025-07-24
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 2025-10-01
E · Potential for more than minimal harm
2025-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K162 · Construction Deficiencies
Fire Safety
Have a combustible roofing system that meets safety standards.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
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 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-01
F · Potential for more than minimal harm
2024-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-30
F · Potential for more than minimal harm
2024-06-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-07-02
F · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-06-27
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 2024-08-30
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-27
F · Potential for more than minimal harm
2024-06-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-27
F · Potential for more than minimal harm
2024-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-27
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 2024-08-30
F · Potential for more than minimal harm
2024-06-27
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-06-26
C · Minimal harm
2024-06-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-16
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-07-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
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 2025-10-01
D · Potential for more than minimal harm
2025-07-24
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 2025-10-01
D · Potential for more than minimal harm
2025-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-04-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
J · Immediate jeopardy
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-04
G · Actual harm
2024-06-27
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 2024-06-21
E · Potential for more than minimal harm
2024-06-27
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 2024-08-14
D · Potential for more than minimal harm
2024-06-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
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 2024-08-14
D · Potential for more than minimal harm
2024-06-27
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 2024-08-14
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
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 2024-08-14
D · Potential for more than minimal harm
2024-06-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
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 2024-08-14
D · Potential for more than minimal harm
2024-06-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
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 2024-08-14
B · Minimal harm
2024-06-27
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-08-14
B · Minimal harm
2024-06-27
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-08-14
D · Potential for more than minimal harm
2023-09-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-08-10
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 2023-09-29
D · Potential for more than minimal harm
2023-08-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-10
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-10
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 2023-09-29
D · Potential for more than minimal harm
2023-08-10
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 2023-09-29
D · Potential for more than minimal harm
2023-08-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-07-03
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 2023-08-02
D · Potential for more than minimal harm
2023-07-03
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-07-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-07-03
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-06-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
$26,685
2025-03-07
Fine
Fine · fine $26,685
Fine
Ownership
Senior Care Communities
5% Or Greater Direct Ownership Interest · Organization
Karel, Mike
Operational/Managerial Control · Individual
King, Ryan
Operational/Managerial Control · Individual
King, Ryan
Corporate Officer · Individual
Lifespark Management Services
Operational/Managerial Control · Organization
Marshall, Susan
Corporate Director · Individual
Parmar, Mona
Operational/Managerial Control · Individual
Sounthala, Nicole
Operational/Managerial Control · Individual
Toulouse, Molly
Corporate Director · Individual
Twsl. LLC
Operational/Managerial Control · Organization
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 2-star inspections with $151,799 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Norris Square
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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