Bayshore Nursing & Rehab

Penalties

• Oct 30, 2024 — Payment Denial · payment denial 36 days

Inspection findings

1. Apr 30, 2026 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected May 22, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

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

     Corrected May 22, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0658 Resident Assessment and Care Planning Deficiencies

     Ensure services provided by the nursing facility meet professional standards of quality.

     Corrected May 22, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 22, 2026 · CMS health inspection

2. Sep 30, 2025 Fire Safety · 59 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Jan 5, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0577 Resident Rights Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     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 Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0585 Resident Rights Deficiencies

     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 Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Nov 12, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0700 Quality of Life and Care Deficiencies

     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.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     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 Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0730 Nursing and Physician Services Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0756 Pharmacy Service Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0790 Quality of Life and Care Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Nov 12, 2025 · CMS health inspection

   • Serious Scope/severity L

     F0835 Administration Deficiencies

     Administer the facility in a manner that enables it to use its resources effectively and efficiently.

     Corrected Nov 12, 2025 · CMS health inspection

   • Serious Scope/severity L

     F0841 Nursing and Physician Services Deficiencies

     Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0887 Infection Control Deficiencies

     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 Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0925 Environmental Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0946 Administration Deficiencies

     Provide training in compliance and ethics.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0947 Nursing and Physician Services Deficiencies

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

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Nov 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

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

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

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

     CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Dec 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Dec 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Dec 15, 2025 · CMS fire safety

3. Jul 30, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Aug 26, 2025 · CMS health inspection

4. Jul 28, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 26, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 26, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 14, 2025 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Aug 26, 2025 · CMS health inspection

5. Jul 3, 2025 Health · 15 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Sep 29, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0692 Quality of Life and Care Deficiencies

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

     Corrected Nov 14, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0697 Quality of Life and Care Deficiencies

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

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0801 Nutrition and Dietary Deficiencies

     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.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0940 Administration Deficiencies

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

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0941 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0942 Resident Rights Deficiencies

     Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0945 Infection Control Deficiencies

     Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0946 Administration Deficiencies

     Provide training in compliance and ethics.

     Corrected Aug 25, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0947 Nursing and Physician Services Deficiencies

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

     Corrected Aug 25, 2025 · CMS health inspection

6. May 29, 2025 Health · 9 findings
   • Not serious Scope/severity D Complaint

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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 Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     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 Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 27, 2025 · CMS health inspection

7. Jan 29, 2025 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0584 Resident Rights Deficiencies

     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 Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     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 Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 27, 2025 · CMS health inspection

8. Oct 30, 2024 Health · 4 findings
   • Not serious Scope/severity F Complaint

     F0584 Resident Rights Deficiencies

     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 Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Dec 2, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Dec 2, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0925 Environmental Deficiencies

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

     Corrected Dec 2, 2024 · CMS health inspection

9. Jul 24, 2024 Health · 1 finding
   • Not serious Scope/severity F Complaint

     F0837 Administration Deficiencies

     Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

     Corrected Aug 15, 2024 · CMS health inspection

10. Jun 20, 2024 Health · 28 findings
    • Not serious Scope/severity D

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0578 Resident Rights Deficiencies

      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 Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0584 Resident Rights Deficiencies

      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 Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0692 Quality of Life and Care Deficiencies

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

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      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 Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0814 Nutrition and Dietary Deficiencies

      Dispose of garbage and refuse properly.

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0908 Environmental Deficiencies

      Keep all essential equipment working safely.

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0919 Environmental Deficiencies

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

      Corrected Jul 25, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity D

      K0225 Egress Deficiencies

      Have stairways and smokeproof enclosures used as exits that meet safety requirements.

      Corrected Jun 18, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0232 Egress Deficiencies

      Have corridors or aisles that are unobstructed and are at least 8 feet in width.

      Corrected Jul 25, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0233 Egress Deficiencies

      Install resident room doors of proper design and width.

      Corrected Jul 25, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0271 Egress Deficiencies

      Have exits that are accessible at all times.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity D

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

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

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity D

      K0355 Smoke Deficiencies

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

      Corrected Jul 25, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0374 Smoke Deficiencies

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

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0521 Services Deficiencies

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

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Jun 21, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0761 Miscellaneous Deficiencies

      To conduct inspection, testing and maintenance of fire doors by qualified individuals.

      Corrected Aug 19, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Aug 19, 2024 · CMS fire safety

11. May 30, 2024 Health · 3 findings
    • Not serious Scope/severity E Complaint

      F0584 Resident Rights Deficiencies

      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 Jun 16, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0655 Resident Assessment and Care Planning Deficiencies

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

      Corrected Jun 16, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jun 16, 2024 · CMS health inspection

12. Oct 10, 2023 Health · 8 findings
    • Not serious Scope/severity D Complaint

      F0584 Resident Rights Deficiencies

      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 Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0585 Resident Rights Deficiencies

      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 Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0801 Nutrition and Dietary Deficiencies

      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.

      Corrected Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0805 Nutrition and Dietary Deficiencies

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

      Corrected Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0806 Nutrition and Dietary Deficiencies

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

      Corrected Nov 7, 2023 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0925 Environmental Deficiencies

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

      Corrected Nov 7, 2023 · CMS health inspection

13. Mar 21, 2023 Health · 37 findings
    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      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 May 17, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0623 Resident Rights Deficiencies

      Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0625 Resident Rights Deficiencies

      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.

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0677 Quality of Life and Care Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Serious Scope/severity G

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jul 24, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0692 Quality of Life and Care Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0698 Quality of Life and Care Deficiencies

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

      Corrected Jun 13, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0755 Pharmacy Service Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0756 Pharmacy Service Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0757 Pharmacy Service Deficiencies

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

      Corrected Jun 13, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      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 May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected May 17, 2023 · CMS health inspection

    • Serious Scope/severity G

      F0760 Pharmacy Service Deficiencies

      Ensure that residents are free from significant medication errors.

      Corrected Jun 13, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      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 May 17, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0800 Nutrition and Dietary Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0804 Nutrition and Dietary Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity C

      F0814 Nutrition and Dietary Deficiencies

      Dispose of garbage and refuse properly.

      Corrected May 17, 2023 · CMS health inspection

    • Serious Scope/severity L

      F0882 Infection Control Deficiencies

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

      Corrected May 17, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0271 Egress Deficiencies

      Have exits that are accessible at all times.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0291 Egress Deficiencies

      Install emergency lighting that can last at least 1 1/2 hours.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

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

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0541 Services Deficiencies

      Install properly constructed and protected linen or trash chutes.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0741 Miscellaneous Deficiencies

      Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0781 Miscellaneous Deficiencies

      Have restrictions on the use of portable space heaters.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0916 Gas, Vacuum, and Electrical Systems Deficiencies

      Have a battery powered remote alarm panel in a location accessible by operating personnel.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0919 Gas, Vacuum, and Electrical Systems Deficiencies

      Meet requirements for the use of electrical equipment.

      Corrected Apr 19, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0920 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper usage of power strips and extension cords.

      Corrected Apr 19, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CHOPP, LYNN — 5% or greater indirect ownership interest, 17%, since 10/01/2019
• CHOPP, MARTIN — 5% or greater indirect ownership interest, 18%, since 10/01/2019
• CHOPP, PNINA — 5% or greater indirect ownership interest, 18%, since 10/01/2019
• CHOPP, RACHEL — 5% or greater indirect ownership interest, 7%, since 10/01/2019
• CHOPP, SARAH — 5% or greater indirect ownership interest, 5%, since 10/01/2019
• CHOPP, SOLOMON — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• NICHOLS, KENNETH — corporate officer, NOT APPLICABLE, since 10/01/2019
• NICHOLS, KENNETH — operational/managerial control, NOT APPLICABLE, since 10/01/2019
• NICHOLS, KENNETH — contracted managing employee, NOT APPLICABLE, since 10/01/2019
• PRAGER, AVROHOM — 5% or greater indirect ownership interest, 13%, since 10/01/2019
• PRAGER, SHULAMIT — 5% or greater indirect ownership interest, 13%, since 10/01/2019
• OPAL HEALTHCARE NJ LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2019