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| Deficiency Category | Inspection Date: 11/9/23 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 1/25/22 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 10/8/19 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 11/9/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 2/25/25Read the full report (PDF) 1/15/25Read the full report (PDF) 11/6/24Read the full report (PDF) 9/26/24Read the full report (PDF) 9/17/24Read the full report (PDF) 8/23/24Read the full report (PDF) 8/13/24Read the full report (PDF) 7/12/24Read the full report (PDF) 4/25/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in California: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 9/17/24 | 10/10/24 | 3 - Actual harm | Few |
Respond appropriately to all alleged violations. | 7/12/24 | 8/6/24 | 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. | 8/13/24 | 8/31/24 | 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. | 9/17/24 | 10/10/24 | 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. | 7/12/24 | 8/6/24 | 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 11/9/23 | 12/9/23 | 3 - Actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/7/24 | 8/28/24 | 1 - Potential for minimal harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/26/24 | 10/10/24 | 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. | 9/17/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 7/12/24 | 8/6/24 | 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 11/9/23 | 1/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/17/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 9/17/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/9/23 | 12/9/23 | 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. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Some |
Implement a program that monitors antibiotic use. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 4/25/24 | 5/1/24 | 1 - Potential for minimal harm | Some |
Ensure each resident receives an accurate assessment. | 11/9/23 | 12/9/23 | 1 - Potential for minimal harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 4/25/24 | 5/1/24 | 1 - Potential for minimal harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 11/9/23 | 12/9/23 | 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. | 11/6/24 | 12/6/24 | 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. | 8/23/24 | 9/23/24 | 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. | 7/12/24 | 8/6/24 | 1 - Potential for minimal harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure residents have reasonable access to and privacy in their use of communication methods. | 2/5/25 | 2/24/25 | 1 - Potential for minimal harm | Some |
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. | 2/25/25 | 3/10/25 | 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. | 1/15/25 | 1/31/25 | 1 - Potential for minimal harm | Some |
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. | 1/15/25 | 1/31/25 | 1 - Potential for minimal harm | Some |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 11/9/23 | 12/9/23 | 1 - Potential for minimal harm | Some |
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. | 4/3/24 | 4/16/24 | 1 - Potential for minimal harm | Some |
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. | 11/9/23 | 12/9/23 | 1 - Potential for minimal harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 11/9/23 | 12/9/23 | 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 11/9/23 | 12/9/23 | 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Some |
Dispose of garbage and refuse properly. | 11/9/23 | 12/9/23 | 1 - Potential for minimal harm | Some |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 7/12/24 | 8/6/24 | 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 8/7/24 | 8/30/24 | 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. | 8/7/24 | 8/30/24 | 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 11/9/23 | 12/9/23 | 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. | 11/9/23 | 12/9/23 | 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. | 7/12/24 | 8/6/24 | 1 - Potential for minimal harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 1/25/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 1/17/24Read the full report (PDF) 11/9/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in California: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 1/17/24 | 2/17/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Few |
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. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Keep residents' personal and medical records private and confidential. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Dispose of garbage and refuse properly. | 1/25/22 | 2/24/22 | 1 - Potential for minimal harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Many |
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. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 1/25/22 | 2/24/22 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 10/8/19Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 3/10/23Read the full report (PDF) 1/20/23Read the full report (PDF) 1/17/23Read the full report (PDF) 11/29/22Read the full report (PDF) 11/18/22Read the full report (PDF) 11/10/22Read the full report (PDF) 4/19/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in California: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 1/17/23 | 2/16/23 | 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. | 5/4/22 | 6/3/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 10/8/19 | 10/31/19 | 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. | 11/18/22 | 12/17/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/29/22 | 12/28/22 | 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. | 11/10/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/10/23 | 4/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 10/8/19 | 10/31/19 | 1 - Potential for minimal harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 11/10/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 10/8/19 | 10/31/19 | 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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Assure that each resident’s assessment is updated at least once every 3 months. | 10/8/19 | 10/31/19 | 1 - Potential for minimal harm | Some |
Ensure a qualified health professional conducts resident assessments. | 10/8/19 | 10/31/19 | 1 - Potential for minimal harm | Some |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | 1/20/23 | 2/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 4/19/22 | 5/17/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 10/8/19 | 10/31/19 | 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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 3/10/23 | 4/9/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/8/19 | 10/31/19 | 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. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure that a working call system is available in each resident's bathroom and bathing area. | 10/8/19 | 10/31/19 | 2 - Minimal harm or potential for actual harm | Few |
| No Administration Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 9/17/24 | 10/10/24 | 3 - Actual harm | Few |
Respond appropriately to all alleged violations. | 7/12/24 | 8/6/24 | 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. | 8/13/24 | 8/31/24 | 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. | 9/17/24 | 10/10/24 | 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. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/7/24 | 8/28/24 | 1 - Potential for minimal harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/26/24 | 10/10/24 | 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. | 9/17/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 11/9/23 | 1/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/17/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 9/17/24 | 10/10/24 | 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. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 11/9/23 | 12/9/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 7/12/24 | 8/6/24 | 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. | 4/25/24 | 5/1/24 | 1 - Potential for minimal harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 4/25/24 | 5/1/24 | 1 - Potential for minimal harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 11/6/24 | 12/6/24 | 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. | 8/23/24 | 9/23/24 | 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. | 7/12/24 | 8/6/24 | 1 - Potential for minimal harm | Some |
Ensure residents have reasonable access to and privacy in their use of communication methods. | 2/5/25 | 2/24/25 | 1 - Potential for minimal harm | Some |
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. | 2/25/25 | 3/10/25 | 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. | 1/15/25 | 1/31/25 | 1 - Potential for minimal harm | Some |
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. | 1/15/25 | 1/31/25 | 1 - Potential for minimal harm | Some |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 11/9/23 | 12/9/23 | 1 - Potential for minimal harm | Some |
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. | 4/3/24 | 4/16/24 | 1 - Potential for minimal harm | Some |
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. | 11/9/23 | 12/9/23 | 1 - Potential for minimal harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/12/24 | 8/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 8/7/24 | 8/30/24 | 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. | 8/7/24 | 8/30/24 | 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. | 7/12/24 | 8/6/24 | 1 - Potential for minimal harm | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 1/17/24 | 2/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 1/17/23 | 2/16/23 | 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. | 5/4/22 | 6/3/22 | 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. | 11/18/22 | 12/17/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/29/22 | 12/28/22 | 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. | 11/10/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 3/10/23 | 4/9/23 | 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. | 11/10/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | 1/20/23 | 2/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 4/19/22 | 5/17/22 | 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. | 3/10/23 | 4/9/23 | 2 - Minimal harm or potential for actual harm | Some |
| This nursing home has not had any infection control inspections in the past 3 years. |