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| Deficiency Category | Inspection Date: 10/11/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 10/20/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 4/14/21 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: | 10/11/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 2/20/25Read the full report (PDF) 1/31/25Read the full report (PDF) 12/27/24Read the full report (PDF) 12/11/24Read the full report (PDF) 11/12/24Read the full report (PDF) 10/22/24Read the full report (PDF) 9/24/24Read the full report (PDF) 9/12/24Read the full report (PDF) 7/10/24Read the full report (PDF) 5/31/24Read 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) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 12/11/24 | 12/25/24 | 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. | 9/12/24 | 10/4/24 | 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) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/31/25 | 3/14/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 10/11/24 | 11/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/11/24 | 11/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 10/11/24 | 11/7/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 10/11/24 | 12/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 10/11/24 | 11/7/24 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/8/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/11/24 | 12/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/11/24 | 12/16/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/22/24 | 11/15/24 | 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. | 10/11/24 | 11/7/24 | 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 and implement an infection prevention and control program. | 10/11/24 | 12/16/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 5/31/24 | 6/10/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 11/12/24 | 12/4/24 | 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) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 1/31/25 | 3/14/25 | 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. | 7/10/24 | 8/2/24 | 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. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 5/31/24 | 6/10/24 | 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. | 10/11/24 | 11/7/24 | 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. | 7/10/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/11/24 | 12/16/24 | 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) |
|---|---|---|---|---|
Post nurse staffing information every day. | 7/10/24 | 8/2/24 | 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 12/27/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 10/22/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 10/11/24 | 11/7/24 | 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. | 10/11/24 | 11/7/24 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/11/24 | 12/16/24 | 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. | 7/10/24 | 8/2/24 | 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) |
|---|---|---|---|---|
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. | 2/20/25 | 3/13/25 | 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. | 10/11/24 | 12/16/24 | 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. | 10/11/24 | 12/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 10/11/24 | 11/7/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 10/11/24 | 11/7/24 | 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. | 10/11/24 | 11/7/24 | 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) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 1/31/25 | 3/14/25 | 2 - Minimal harm or potential for actual harm | Some |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 10/20/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 3/19/24Read the full report (PDF) 12/28/23Read the full report (PDF) 11/29/23Read the full report (PDF) 11/7/23Read the full report (PDF) 7/20/23Read the full report (PDF) 6/22/23Read the full report (PDF) 5/30/23Read 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) |
|---|---|---|---|---|
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 7/20/23 | 8/1/23 | 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. | 5/30/23 | 6/16/23 | 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. | 12/28/23 | 1/22/24 | 3 - 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. | 3/19/24 | 4/11/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/20/23 | 11/16/23 | 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. | 10/20/23 | 11/16/23 | 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. | 6/22/23 | 7/17/23 | 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. | 5/30/23 | 6/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 10/20/23 | 11/16/23 | 3 - 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. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Implement a program that monitors antibiotic use. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 10/20/23 | 11/16/23 | 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) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 3/19/24 | 5/16/24 | 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. | 10/20/23 | 11/16/23 | 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. | 11/7/23 | 11/15/23 | 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. | 7/20/23 | 8/1/23 | 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. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 7/20/23 | 8/1/23 | 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) |
|---|---|---|---|---|
Post nurse staffing information every day. | 11/29/23 | 12/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 11/29/23 | 12/27/23 | 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) |
|---|---|---|---|---|
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | 11/29/23 | 12/27/23 | 2 - Minimal harm or potential for actual harm | Some |
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. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 7/20/23 | 8/1/23 | 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. | 11/29/23 | 12/23/23 | 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. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 10/20/23 | 12/29/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 10/20/23 | 11/16/23 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 11/29/23 | 12/27/23 | 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. | 10/20/23 | 11/16/23 | 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. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Some |
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. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 10/20/23 | 12/29/23 | 2 - Minimal harm or potential for actual harm | Some |
| 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) |
|---|---|---|---|---|
Provide timely, quality laboratory services/tests to meet the needs of residents. | 9/8/23 | 9/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | 10/20/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 4/14/21Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 2/26/23Read the full report (PDF) 11/1/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 11/16/22Read the full report (PDF) 4/18/22Read the full report (PDF) |
| 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: |
| No Freedom from Abuse, Neglect, and Exploitation 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/26/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/1/22 | 11/15/22 | 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 and implement an infection prevention and control program. | 9/9/22 | 9/19/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 4/14/21 | 5/4/21 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 4/14/21 | 4/22/21 | 2 - Minimal harm or potential for actual harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 4/14/21 | 4/22/21 | 2 - Minimal harm or potential for actual harm | Few |
Ensure a qualified health professional conducts resident assessments. | 4/14/21 | 4/16/21 | 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) |
|---|---|---|---|---|
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. | 4/14/21 | 4/14/21 | 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) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/14/21 | 4/30/21 | 2 - Minimal harm or potential for actual harm | Some |
Allow residents to self-administer drugs if determined clinically appropriate. | 4/14/21 | 5/3/21 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary 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 that residents are free from significant medication errors. | 4/14/21 | 4/26/21 | 4 - Immediate jeopardy to resident health or safety | Some |
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. | 4/14/21 | 5/3/21 | 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) |
|---|---|---|---|---|
Hire a qualified full-time social worker in a facility with more than 120 beds. | 4/14/21 | 5/5/21 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date 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. | 12/11/24 | 12/25/24 | 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. | 9/12/24 | 10/4/24 | 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. | 1/31/25 | 3/14/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/8/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/22/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 5/31/24 | 6/10/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 11/12/24 | 12/4/24 | 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. | 1/31/25 | 3/14/25 | 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. | 7/10/24 | 8/2/24 | 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. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 5/31/24 | 6/10/24 | 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. | 7/10/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Post nurse staffing information every day. | 7/10/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 12/27/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 9/24/24 | 10/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 10/22/24 | 11/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 9/24/24 | 10/17/24 | 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. | 7/10/24 | 8/2/24 | 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. | 2/20/25 | 3/13/25 | 2 - Minimal harm or potential for actual harm | Few |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 1/31/25 | 3/14/25 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 7/20/23 | 8/1/23 | 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. | 5/30/23 | 6/16/23 | 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. | 12/28/23 | 1/22/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/19/24 | 4/11/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/22/23 | 7/17/23 | 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. | 5/30/23 | 6/16/23 | 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. | 3/19/24 | 5/16/24 | 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. | 11/7/23 | 11/15/23 | 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. | 7/20/23 | 8/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 7/20/23 | 8/1/23 | 1 - Potential for minimal harm | Some |
Post nurse staffing information every day. | 11/29/23 | 12/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 11/29/23 | 12/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | 11/29/23 | 12/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 7/20/23 | 8/1/23 | 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. | 11/29/23 | 12/23/23 | 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. | 11/29/23 | 12/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely, quality laboratory services/tests to meet the needs of residents. | 9/8/23 | 9/28/23 | 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. | 2/26/23 | 2/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/1/22 | 11/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 9/9/22 | 9/19/22 | 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 and implement an infection prevention and control program. | 9/9/22 | 9/19/22 | 2 - Minimal harm or potential for actual harm | Few |