Facility Watch Inspection records for every certified US nursing home

Elkton Nursing and Rehabilitation Center

1 Price Drive
Elkton, MD 21921
(410) 398-6474

Special Focus Facility — SFF Candidate
CCN
215269
Certified beds
182
Ownership
For profit - Limited Liability company
Chain
Lifeworks Rehab

Nurse staffing

3.48
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.44 hours per resident per day

Nursing staff turnover: 50% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected January 29, 2026

5 citations · from a complaint investigation · Health
D
F0684 No 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 February 12, 2026
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected February 12, 2026
D
F0689 No 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 February 12, 2026
D
F0770 No actual harm with potential for more than minimal harm · Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Deficient, Provider has date of correction · corrected February 12, 2026
E
F0757 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected February 12, 2026

Inspected October 9, 2025

36 citations · from a complaint investigation · Health
D
F0563 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Deficient, Provider has date of correction · corrected January 6, 2026
D
F0578 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0628 No actual harm with potential for more than minimal harm · Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0656 No 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 December 2, 2025
D
F0657 No 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 February 12, 2026
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0695 No 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 December 2, 2025
D
F0745 No 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 December 2, 2025
D
F0755 No 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 December 2, 2025
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0774 No actual harm with potential for more than minimal harm · Isolated

Help the resident with transportation to and from laboratory services outside of the facility.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0801 No actual harm with potential for more than minimal harm · Isolated

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 December 2, 2025
D
F0806 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Deficient, Provider has date of correction · corrected December 2, 2025
D
F0842 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 2, 2025
E
F0550 No actual harm with potential for more than minimal harm · Pattern

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 December 2, 2025
E
F0689 No actual harm with potential for more than minimal harm · Pattern

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 2, 2025
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected December 2, 2025
E
F0805 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Deficient, Provider has date of correction · corrected February 12, 2026
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected February 12, 2026
E
F0921 No actual harm with potential for more than minimal harm · Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected December 2, 2025
E
F0925 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0565 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected January 6, 2026
F
F0567 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected January 6, 2026
F
F0584 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0800 No actual harm with potential for more than minimal harm · Widespread

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0803 No actual harm with potential for more than minimal harm · Widespread

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0804 No actual harm with potential for more than minimal harm · Widespread

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0812 No 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 December 2, 2025
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0840 No actual harm with potential for more than minimal harm · Widespread

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Deficient, Provider has date of correction · corrected December 2, 2025
F
F0908 No actual harm with potential for more than minimal harm · Widespread

Keep all essential equipment working safely.

Deficient, Provider has date of correction · corrected December 2, 2025
G
F0684 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected December 2, 2025
G
F0697 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected December 2, 2025

Inspected July 2, 2025

25 citations · from a complaint investigation · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0550 No 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 August 16, 2025
D
F0580 No 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 August 16, 2025
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0602 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0609 No 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 August 16, 2025
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0677 No 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 August 16, 2025
D
F0685 No actual harm with potential for more than minimal harm · Isolated

Assist a resident in gaining access to vision and hearing services.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0689 No 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 August 16, 2025
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0692 No 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 August 16, 2025
D
F0695 No 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 August 16, 2025
D
F0755 No 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 August 16, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0779 No actual harm with potential for more than minimal harm · Isolated

Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0840 No actual harm with potential for more than minimal harm · Isolated

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Deficient, Provider has date of correction · corrected August 16, 2025
D
F0842 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 16, 2025
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected August 16, 2025
E
F0641 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected August 16, 2025
E
F0684 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 16, 2025
E
F0757 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected August 16, 2025
E
F0925 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 16, 2025

Inspected November 20, 2023

50 citations · from a complaint investigation · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0550 No 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 January 17, 2024
D
F0609 No 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 January 17, 2024
D
F0622 No actual harm with potential for more than minimal harm · Isolated

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0624 No actual harm with potential for more than minimal harm · Isolated

Prepare residents for a safe transfer or discharge from the nursing home.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0692 No 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 January 17, 2024
D
F0693 No actual harm with potential for more than minimal harm · Isolated

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0697 No 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 January 17, 2024
D
F0699 No actual harm with potential for more than minimal harm · Isolated

Provide care or services that was trauma informed and/or culturally competent.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0700 No actual harm with potential for more than minimal harm · Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0710 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0711 No actual harm with potential for more than minimal harm · Isolated

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0727 No actual harm with potential for more than minimal harm · Isolated

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 January 17, 2024
D
F0730 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0849 No actual harm with potential for more than minimal harm · Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0867 No actual harm with potential for more than minimal harm · Isolated

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected January 17, 2024
D
F0943 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0565 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0578 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0585 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0623 No actual harm with potential for more than minimal harm · Pattern

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 January 17, 2024
E
F0625 No actual harm with potential for more than minimal harm · Pattern

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0656 No actual harm with potential for more than minimal harm · Pattern

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 January 17, 2024
E
F0657 No 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 January 17, 2024
E
F0684 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0695 No 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 January 17, 2024
E
F0726 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0745 No actual harm with potential for more than minimal harm · Pattern

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0755 No actual harm with potential for more than minimal harm · Pattern

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 January 17, 2024
E
F0756 No actual harm with potential for more than minimal harm · Pattern

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 January 17, 2024
E
F0759 No actual harm with potential for more than minimal harm · Pattern

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0804 No actual harm with potential for more than minimal harm · Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0842 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0883 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected January 17, 2024
E
F0908 No actual harm with potential for more than minimal harm · Pattern

Keep all essential equipment working safely.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0741 No actual harm with potential for more than minimal harm · Widespread

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0801 No 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 January 17, 2024
F
F0812 No 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 January 17, 2024
F
F0835 No 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.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0881 No actual harm with potential for more than minimal harm · Widespread

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0882 No actual harm with potential for more than minimal harm · Widespread

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Deficient, Provider has date of correction · corrected January 17, 2024
F
F0887 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected January 17, 2024

Inspected August 25, 2023

1 citation · from a complaint investigation · Health
J
F0689 Immediate jeopardy to resident health or safety · 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 August 25, 2023

Inspected June 26, 2023

31 citations · from a complaint investigation · Health
C
F0577 No actual harm with potential for minimal harm · Widespread

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Deficient, Provider has date of correction · corrected August 1, 2023
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0607 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0609 No 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 August 1, 2023
D
F0622 No actual harm with potential for more than minimal harm · Isolated

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0656 No 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 August 1, 2023
D
F0657 No 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 August 1, 2023
D
F0660 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0684 No 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 August 1, 2023
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0692 No 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 August 1, 2023
D
F0695 No 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 August 1, 2023
D
F0710 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0711 No actual harm with potential for more than minimal harm · Isolated

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0712 No actual harm with potential for more than minimal harm · Isolated

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0755 No 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 August 1, 2023
D
F0756 No 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 August 1, 2023
D
F0757 No 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 August 1, 2023
D
F0770 No actual harm with potential for more than minimal harm · Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0806 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0940 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 1, 2023
D
F0943 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 1, 2023
E
F0580 No actual harm with potential for more than minimal harm · Pattern

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 August 1, 2023
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected August 1, 2023
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected August 1, 2023
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected August 1, 2023
E
F0842 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 1, 2023
F
F0761 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected August 1, 2023
F
F0801 No 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 August 1, 2023

Inspected August 13, 2021

25 citations · Health
D
F0550 No 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 17, 2021
D
F0580 No 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 17, 2021
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0656 No 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 September 17, 2021
D
F0677 No 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 September 17, 2021
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0689 No 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 17, 2021
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0695 No 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 17, 2021
D
F0744 No 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 17, 2021
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0790 No actual harm with potential for more than minimal harm · Isolated

Provide routine and 24-hour emergency dental care for each resident.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0791 No actual harm with potential for more than minimal harm · Isolated

Provide or obtain dental services for each resident.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0803 No actual harm with potential for more than minimal harm · Isolated

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0804 No 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 17, 2021
D
F0812 No actual harm with potential for more than minimal harm · Isolated

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 17, 2021
D
F0840 No actual harm with potential for more than minimal harm · Isolated

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Deficient, Provider has date of correction · corrected September 17, 2021
D
F0880 No 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 September 17, 2021
E
F0657 No 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 17, 2021
E
F0684 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected September 17, 2021
E
F0842 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected September 17, 2021
E
F0919 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected September 17, 2021

Penalties

DateTypeAmount
October 9, 2025Fine$9,249
October 9, 2025Fine$16,812
October 9, 2025Payment Denial · 34 days
August 25, 2023Fine$5,073