Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.45 hours per resident per day
Nursing staff turnover: 51% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 29, 2025
2 citations · from a complaint investigation · Health
F
F0726No actual harm with potential for more than minimal harm · Widespread
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.
Past Non-Compliance · corrected December 23, 2024
F
F0835No actual harm with potential for more than minimal harm · Widespread
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Past Non-Compliance · corrected December 23, 2024
Inspected August 29, 2024
12 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0744No actual harm with potential for more than minimal harm · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0804No actual harm with potential for more than minimal harm · Isolated
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected September 26, 2024
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected September 26, 2024
F
F0727No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected September 26, 2024
F
F0801No actual harm with potential for more than minimal harm · Widespread
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Deficient, Provider has date of correction · corrected September 26, 2024
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected September 26, 2024
F
F0851No actual harm with potential for more than minimal harm · Widespread
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Deficient, Provider has date of correction · corrected September 26, 2024
Inspected June 3, 2024
1 citation · from a complaint investigation · Health
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past Non-Compliance · corrected May 23, 2024
Inspected April 1, 2024
3 citations · from a complaint investigation · Health
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected April 15, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 15, 2024
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected April 15, 2024
Inspected March 4, 2024
4 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 3, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 3, 2024
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected April 3, 2024
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected April 3, 2024
Inspected November 28, 2023
1 citation · from a complaint investigation · Health
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected December 22, 2023
Inspected August 31, 2023
15 citations · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0740No actual harm with potential for more than minimal harm · Isolated
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0745No actual harm with potential for more than minimal harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0804No actual harm with potential for more than minimal harm · Isolated
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected September 30, 2023
D
F0908No actual harm with potential for more than minimal harm · Isolated
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected September 30, 2023
E
F0657No actual harm with potential for more than minimal harm · Pattern
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected September 30, 2023
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected September 30, 2023
F
F0727No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected September 30, 2023
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected September 30, 2023
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 30, 2023
Inspected March 17, 2022
13 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected April 15, 2022
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 15, 2022
E
F0695No actual harm with potential for more than minimal harm · Pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 15, 2022
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 15, 2022
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected April 15, 2022
G
F0697Actual harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected April 15, 2022
Penalties
Date
Type
Amount
June 3, 2024
Fine
$13,039
March 4, 2024
Fine
$12,035
November 28, 2023
Fine
$24,863
August 31, 2023
Fine
$25,526
August 31, 2023
Payment Denial · 2 days
Ownership transfers
Effective
Seller
Buyer
08/01/2019
THE Evangelical Lutheran Good Samaritan Society
Topside Manor INC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.