Burgh Care Center

For profit - Corporation  ·  909 West Street, Pittsburgh, PA 15221  ·  See home’s Medicare page

Special Focus Facility Candidate
Has a history of serious quality issues but has not been formally flagged by the government.
Affiliated With Wecare Centers
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
3.39
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.9
51.4%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 44.5%
126
Certified beds
Qualifying beds in the certified provider or supplier facility.
70
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Pennwood Holdings LLC (100%) since Nov, 2023
Indirect owners
Aryeh Grinspan (40%) since Nov, 2023
Gedaliah Wielgus (40%) since Nov, 2023
Eli Korn (20%) since Nov, 2023
Managerial control
Wecare Hcc LLC since Nov, 2023
Amardeep Angroola since Dec, 2025
Aryeh Grinspan since Nov, 2023
Gedaliah Wielgus since Nov, 2023
Cristine Williams since Jul, 2025
Managing employee(s)
No information available
Managing Control Governing Body
Aryeh Grinspan since Nov, 2023
Gedaliah Wielgus since Nov, 2023
Cristine Williams since Oct, 2024
Corporate Officer
Aryeh Grinspan since Nov, 2023
Gedaliah Wielgus since Nov, 2023
Adp Of The Snf
909 W Street Holdings LLC since Nov, 2023
909 West Street Realty LLC since Nov, 2023
A&C Einhorn Family Trust since Nov, 2023
Wecare Hcc LLC since Nov, 2023
Amardeep Angroola since Dec, 2025
Aryeh Grinspan since Nov, 2023
Lori Mcnellie since Nov, 2023
Gedaliah Wielgus since Nov, 2023
Cristine Williams since Jul, 2025

Inspection Reports

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
120

total deficiencies

11

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Apr 10, 2026
Standard report
35 deficiencies
(4 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

C

to F
F

Nutrition and Dietary Deficiency — F0801
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0605
Failure to: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0628
Failure to: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0695
Failure to: Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0730
Failure to: Observe each nurse aide's job performance and give regular training.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0756
Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0803
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0881
Failure to: Implement a program that monitors antibiotic use.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0941
Failure to: Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0942
Failure to: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0943
Failure to: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0944
Failure to: Conduct mandatory training, for all staff, on the facility's Quality Assurance and Performance Improvement Program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0945
Failure to: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0946
Failure to: Provide training in compliance and ethics.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0947
Failure to: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Administration Deficiency — F0949
Failure to: Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to: Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0620
Failure to: Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0690
Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0691
Failure to: Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0847
Failure to: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0883
Failure to: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0887
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Environmental Deficiency — F0908
Failure to: Keep all essential equipment working safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0575
Failure to: Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
C

Resident Rights Deficiency — F0577
Failure to: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
C

Resident Rights Deficiency — F0579
Failure to: Provide information about how to apply for and use Medicare and Medicaid benefits.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
C

Jan 29, 2026
Complaint report
1 deficiency
D

Resident Rights Deficiency — F0584
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Dec 4, 2025
Complaint report
3 deficiencies
D

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0840
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0844
Failure to: Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 22, 2025
Complaint report
1 deficiency
D

Environmental Deficiency — F0917
Failure to: Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Apr 28, 2025
Complaint report
1 deficiency
G

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Apr 5, 2025
Complaint report
1 deficiency
F

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Apr 5, 2025
Standard report
36 deficiencies
(3 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

to J
J

Quality of Life and Care Deficiency — F0695
Failure to: Provide safe and appropriate respiratory care for a resident when needed.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Nutrition and Dietary Deficiency — F0803
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Infection Control Deficiency — F0881
Failure to: Implement a program that monitors antibiotic use.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Infection Control Deficiency — F0882
Failure to: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Administration Deficiency — F0944
Failure to: Conduct mandatory training, for all staff, on the facility's Quality Assurance and Performance Improvement Program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Quality of Life and Care Deficiency — F0679
Failure to: Provide activities to meet all resident's needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0680
Failure to: Ensure the activities program is directed by a qualified professional.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0725
Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0726
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0730
Failure to: Observe each nurse aide's job performance and give regular training.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0755
Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0584
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0620
Failure to: Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0637
Failure to: Assess the resident when there is a significant change in condition
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0685
Failure to: Assist a resident in gaining access to vision and hearing services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0690
Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0692
Failure to: Provide enough food/fluids to maintain a resident's health.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0693
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0694
Failure to: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0699
Failure to: Provide care or services that was trauma informed and/or culturally competent.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0756
Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0758
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0760
Failure to: Ensure that residents are free from significant medication errors.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0806
Failure to: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0809
Failure to: Ensure meals and snacks are served at times in accordance with resident's needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0840
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0867
Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 13, 2025
Complaint report
6 deficiencies
$175,400 Fine
1 Payment Suspension
D

to J
J

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

Administration Deficiency — F0835
Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Nursing and Physician Services Deficiency — F0841
Failure to: Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to: Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0660
Failure to: Plan the resident's discharge to meet the resident's goals and needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nursing and Physician Services Deficiency — F0712
Failure to: Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 1, 2024
Complaint report
6 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

Resident Rights Deficiency — F0572
Failure to: Give residents a notice of rights, rules, services and charges.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0580
Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0760
Failure to: Ensure that residents are free from significant medication errors.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 14, 2024
Complaint report
3 deficiencies
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to: Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jun 21, 2024
Complaint report
3 deficiencies
D

to K
K

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
K

Administration Deficiency — F0835
Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Resident Assessment and Care Planning Deficiency — F0660
Failure to: Plan the resident's discharge to meet the resident's goals and needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 24, 2024
Standard report
19 deficiencies
(3 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

$168,384 Fine
D

to F
F

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Resident Assessment and Care Planning Deficiency — F0641
Failure to: Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0695
Failure to: Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0698
Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0726
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nursing and Physician Services Deficiency — F0730
Failure to: Observe each nurse aide's job performance and give regular training.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0881
Failure to: Implement a program that monitors antibiotic use.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0882
Failure to: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0584
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to: Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0686
Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0688
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0690
Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0756
Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0803
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 19, 2024
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jan 10, 2024
Complaint report
1 deficiency
D

Resident Rights Deficiency — F0622
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nov 22, 2023
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 2, 2023
Complaint report
2 deficiencies
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
$347K

total fines

1

payment suspension

Mar 13, 2025
1 Payment Suspension
May 24, 2024
Feb 6, 2024
No corresponding inspection report.