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Health Inspection Summary
The Pavilion at Ocean Point
3202 Duke Street
San Diego, CA 92110
(619) 224-4141

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Deficiency Category
Inspection Date:
10/24/24
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
10/26/23
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
10/19/22
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies023
Quality of Life and Care Deficiencies4212
Infection Control Deficiencies230
Resident Assessment and Care Planning Deficiencies664
Nursing and Physician Services Deficiencies011
Resident Rights Deficiencies759
Nutrition and Dietary Deficiencies211
Pharmacy Service Deficiencies752
Environmental Deficiencies101
Administration Deficiencies113

Detailed result for inspection on 10/24/24
Date of last standard health inspection:10/24/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:30
Average number of Health Deficiencies in California:16.4
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Some

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Few

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

10/10/2410/29/24
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Few

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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

6/17/247/15/24
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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

5/21/246/18/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

Keep residents' personal and medical records private and confidential.

9/4/249/26/24
2 - Minimal harm or potential for actual harm
Few

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.

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

8/2/249/5/24
2 - Minimal harm or potential for actual harm
Few

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

4/18/245/15/24
2 - Minimal harm or potential for actual harm
Few

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

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.

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

10/24/2411/21/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 10/26/23
Date of last standard health inspection:10/26/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
Total number of Health Deficiencies for this nursing home:26
Average number of Health Deficiencies in California:17.2
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

12/21/231/12/24
2 - Minimal harm or potential for actual harm
Few

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

8/4/238/21/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

9/24/2310/11/23
2 - Minimal harm or potential for actual harm
Some

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

3/22/233/28/23
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

6/19/237/19/23
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

10/26/2312/5/23
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

9/24/2310/11/23
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

12/21/231/12/24
2 - Minimal harm or potential for actual harm
Few

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

9/14/2310/11/23
2 - Minimal harm or potential for actual harm
Few

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

10/26/2312/5/23
2 - Minimal harm or potential for actual harm
Few

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

6/19/237/19/23
2 - Minimal harm or potential for actual harm
Few

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

8/1/238/31/23
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

10/26/2312/5/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

8/3/238/31/23
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Give the resident's representative the ability to exercise the resident's rights.

9/14/2310/11/23
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

9/24/2310/11/23
2 - Minimal harm or potential for actual harm
Few

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.

10/26/2312/5/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

10/26/2312/5/23
2 - Minimal harm or potential for actual harm
Few

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

6/19/237/19/23
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

9/18/2310/9/23
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

4/12/234/30/23
2 - Minimal harm or potential for actual harm
Few

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

10/2/2310/22/23
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

1/25/242/23/24
2 - Minimal harm or potential for actual harm
Few

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.

4/21/235/16/23
2 - Minimal harm or potential for actual harm
Few

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.

9/14/2310/11/23
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

10/26/2312/5/23
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 10/19/22
Date of last standard health inspection:10/19/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:36
Average number of Health Deficiencies in California:15.1
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

5/27/226/7/22
2 - Minimal harm or potential for actual harm
Few

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

Ensure that each resident is free from medications that restrain them, unless needed for medical treatment.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

4/5/226/2/22
2 - Minimal harm or potential for actual harm
Few

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

9/29/2210/29/22
2 - Minimal harm or potential for actual harm
Few

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Some

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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

1/3/231/30/23
2 - Minimal harm or potential for actual harm
Few

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

1/17/231/23/23
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

9/29/2210/29/22
2 - Minimal harm or potential for actual harm
Some

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

9/16/229/23/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Post nurse staffing information every day.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

2/28/233/30/23
2 - Minimal harm or potential for actual harm
Few

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.

2/7/233/15/23
2 - Minimal harm or potential for actual harm
Some

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

9/16/229/23/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Some

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

9/29/2210/29/22
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

9/15/2210/31/22
2 - Minimal harm or potential for actual harm
Few

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.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few

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.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Keep all essential equipment working safely.

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

6/11/226/27/22
2 - Minimal harm or potential for actual harm
Few

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Some

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

10/19/2211/19/22
2 - Minimal harm or potential for actual harm
Few
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Some

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Few

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

10/10/2410/29/24
2 - Minimal harm or potential for actual harm
Few

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

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Few

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

6/17/247/15/24
2 - Minimal harm or potential for actual harm
Few

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

5/21/246/18/24
2 - Minimal harm or potential for actual harm
Few

Keep residents' personal and medical records private and confidential.

9/4/249/26/24
2 - Minimal harm or potential for actual harm
Few

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.

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Some

Ensure that residents are free from significant medication errors.

8/2/249/5/24
2 - Minimal harm or potential for actual harm
Few

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

4/18/245/15/24
2 - Minimal harm or potential for actual harm
Few

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.

9/24/2410/3/24
2 - Minimal harm or potential for actual harm
Some

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

12/21/231/12/24
2 - Minimal harm or potential for actual harm
Few

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

8/4/238/21/23
2 - Minimal harm or potential for actual harm
Few

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

9/24/2310/11/23
2 - Minimal harm or potential for actual harm
Some

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

3/22/233/28/23
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

6/19/237/19/23
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

9/24/2310/11/23
2 - Minimal harm or potential for actual harm
Some

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

12/21/231/12/24
2 - Minimal harm or potential for actual harm
Few

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

9/14/2310/11/23
2 - Minimal harm or potential for actual harm
Few

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

6/19/237/19/23
2 - Minimal harm or potential for actual harm
Few

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

8/1/238/31/23
2 - Minimal harm or potential for actual harm
Few

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

8/3/238/31/23
2 - Minimal harm or potential for actual harm
Few

Give the resident's representative the ability to exercise the resident's rights.

9/14/2310/11/23
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

9/24/2310/11/23
2 - Minimal harm or potential for actual harm
Few

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

6/19/237/19/23
2 - Minimal harm or potential for actual harm
Few

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

9/18/2310/9/23
2 - Minimal harm or potential for actual harm
Few

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

4/12/234/30/23
2 - Minimal harm or potential for actual harm
Few

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

10/2/2310/22/23
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

1/25/242/23/24
2 - Minimal harm or potential for actual harm
Few

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.

4/21/235/16/23
2 - Minimal harm or potential for actual harm
Few

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.

9/14/2310/11/23
2 - Minimal harm or potential for actual harm
Few

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

5/27/226/7/22
2 - Minimal harm or potential for actual harm
Few

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

4/5/226/2/22
2 - Minimal harm or potential for actual harm
Few

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

9/29/2210/29/22
2 - Minimal harm or potential for actual harm
Few

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

1/3/231/30/23
2 - Minimal harm or potential for actual harm
Few

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

1/17/231/23/23
2 - Minimal harm or potential for actual harm
Few

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

9/29/2210/29/22
2 - Minimal harm or potential for actual harm
Some

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

9/16/229/23/22
2 - Minimal harm or potential for actual harm
Few

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.

2/28/233/30/23
2 - Minimal harm or potential for actual harm
Few

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.

2/7/233/15/23
2 - Minimal harm or potential for actual harm
Some

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

9/16/229/23/22
2 - Minimal harm or potential for actual harm
Few

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

9/29/2210/29/22
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

9/15/2210/31/22
2 - Minimal harm or potential for actual harm
Few

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.

6/11/226/27/22
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.
Medicare
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