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| Deficiency Category | Inspection Date: 7/17/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 6/9/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 5/18/22 Complaint Reporting Period: 3/1/22 - 2/28/23 |
|---|---|---|---|
| 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: | 7/17/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 12/2/24Read the full report (PDF) 11/4/24Read the full report (PDF) 10/22/24Read the full report (PDF) 10/1/24Read the full report (PDF) 5/10/24Read the full report (PDF) 3/15/24Read the full report (PDF) |
| 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: | |
| Average number of Health Deficiencies in Illinois: | |
| 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. | 3/15/24 | 3/26/24 | 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. | 12/2/24 | 12/6/24 | 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. | 1/8/25 | 1/14/25 | 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. | 5/10/24 | 5/22/24 | 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. | 7/17/24 | 7/31/24 | 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. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/1/24 | 10/16/24 | 3 - Actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 7/3/24 | 7/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/10/24 | 5/22/24 | 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. | 7/17/24 | 7/31/24 | 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. | 7/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 7/3/24 | 7/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 5/10/24 | 5/22/24 | 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. | 10/1/24 | 11/1/24 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/1/24 | 10/16/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 7/17/24 | 7/31/24 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 7/3/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 7/17/24 | 7/31/24 | 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) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 7/3/24 | 7/23/24 | 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 enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
Post nurse staffing information every day. | 7/17/24 | 7/31/24 | 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) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 7/17/24 | 7/31/24 | 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. | 10/22/24 | 11/1/24 | 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. | 10/1/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
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. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 7/17/24 | 7/31/24 | 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. | 7/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 7/17/24 | 7/31/24 | 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) |
|---|---|---|---|---|
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | 7/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Some |
Dispose of garbage and refuse properly. | 7/17/24 | 7/31/24 | 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) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 11/4/24 | 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) |
|---|---|---|---|---|
Keep all essential equipment working safely. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 6/9/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 12/1/23Read the full report (PDF) 9/27/23Read the full report (PDF) 8/10/23Read the full report (PDF) 5/18/23Read the full report (PDF) 4/13/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| 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. | 12/1/23 | 12/21/23 | 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. | 6/9/23 | 7/17/23 | 3 - Actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 9/27/23 | 10/13/23 | 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. | 2/2/24 | 2/16/24 | 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. | 2/2/24 | 2/16/24 | 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) |
|---|---|---|---|---|
Provide enough food/fluids to maintain a resident's health. | 12/1/23 | 12/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | Some |
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. | 6/9/23 | 6/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 8/10/23 | 8/23/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 6/9/23 | 6/26/23 | 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. | 12/1/23 | 12/21/23 | 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. | 5/18/23 | 5/22/23 | 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. | 4/13/23 | 4/28/23 | 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. | 12/1/23 | 12/21/23 | 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. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | 6/9/23 | 7/17/23 | 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) |
|---|---|---|---|---|
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 4/13/23 | 4/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Assure that each resident’s assessment is updated at least once every 3 months. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | Few |
PASARR screening for Mental disorders or Intellectual Disabilities | 6/9/23 | 6/26/23 | 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) |
|---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 12/1/23 | 12/21/23 | 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 residents are fully informed and understand their health status, care and treatments. | 4/13/23 | 4/28/23 | 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. | 5/18/23 | 5/22/23 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 12/1/23 | 12/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 2/2/24 | 2/16/24 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 4/13/23 | 4/28/23 | 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. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 6/9/23 | 7/17/23 | 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) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | 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. | 6/9/23 | 6/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 6/9/23 | 7/17/23 | 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. | 6/9/23 | 6/26/23 | 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) |
|---|---|---|---|---|
Make sure that a working call system is available in each resident's bathroom and bathing area. | 6/9/23 | 6/26/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 5/18/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | 2/24/23Read the full report (PDF) 12/2/22Read the full report (PDF) 10/24/22Read the full report (PDF) 10/3/22Read the full report (PDF) 9/20/22Read the full report (PDF) 8/26/22Read the full report (PDF) 8/11/22Read the full report (PDF) 6/14/22Read the full report (PDF) 5/18/22Read the full report (PDF) 4/28/22Read the full report (PDF) |
| 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: | |
| Average number of Health Deficiencies in Illinois: | |
| 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) |
|---|---|---|---|---|
Respond appropriately to all alleged violations. | 10/3/22 | 10/18/22 | 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. | 12/2/22 | 12/20/22 | 3 - Actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 6/14/22 | 6/25/22 | 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. | 9/20/22 | 11/11/22 | 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. | 10/24/22 | 11/11/22 | 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. | 10/3/22 | 10/18/22 | 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. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 6/14/22 | 6/25/22 | 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. | 2/24/23 | 3/15/23 | 3 - Actual harm | Few |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 2/24/23 | 3/15/23 | 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/2/22 | 12/20/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/28/22 | 5/13/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 10/3/22 | 10/18/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 8/11/22 | 8/23/22 | 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. | 5/18/22 | 6/11/22 | 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. | 10/24/22 | 11/11/22 | 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. | 4/28/22 | 5/13/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/18/22 | 6/14/22 | 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. | 12/2/22 | 12/20/22 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/28/22 | 5/13/22 | 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. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/3/22 | 10/18/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 6/14/22 | 6/24/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 2/24/23 | 3/15/23 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/24/23 | 3/15/23 | 3 - Actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 2/24/23 | 3/15/23 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 2/24/23 | 3/15/23 | 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. | 5/18/22 | 6/11/22 | 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/24/22 | 11/11/22 | 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. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 2/24/23 | 3/15/23 | 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 enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 10/3/22 | 10/18/22 | 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) |
|---|---|---|---|---|
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. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 5/18/22 | 6/11/22 | 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. | 5/18/22 | 6/11/22 | 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. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Some |
Keep residents' personal and medical records private and confidential. | 5/18/22 | 6/11/22 | 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) |
|---|---|---|---|---|
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 8/26/22 | 9/9/22 | 2 - Minimal harm or potential for actual harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 5/18/22 | 6/11/22 | 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) |
|---|---|---|---|---|
Ensure that residents are free from significant medication errors. | 10/24/22 | 11/11/22 | 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. | 12/2/22 | 12/20/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure medication error rates are not 5 percent or greater. | 5/18/22 | 6/11/22 | 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. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Many |
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. | 5/18/22 | 6/11/22 | 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) |
|---|---|---|---|---|
Put firmly secured handrails on each side of hallways. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 2/24/23 | 3/15/23 | 2 - Minimal harm or potential for actual harm | Many |
| 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. | 3/15/24 | 3/26/24 | 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. | 12/2/24 | 12/6/24 | 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. | 1/8/25 | 1/14/25 | 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. | 5/10/24 | 5/22/24 | 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. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/1/24 | 10/16/24 | 3 - Actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 7/3/24 | 7/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/10/24 | 5/22/24 | 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. | 7/3/24 | 7/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 5/10/24 | 5/22/24 | 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. | 10/1/24 | 11/1/24 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/1/24 | 10/16/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide and implement an infection prevention and control program. | 7/3/24 | 7/31/24 | 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. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 7/3/24 | 7/23/24 | 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. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | 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. | 10/22/24 | 11/1/24 | 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. | 10/1/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
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. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 11/4/24 | 11/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep all essential equipment working safely. | 10/22/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Many |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 12/1/23 | 12/21/23 | 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. | 9/27/23 | 10/13/23 | 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. | 2/2/24 | 2/16/24 | 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. | 2/2/24 | 2/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 12/1/23 | 12/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 6/9/23 | 7/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide activities to meet all resident's needs. | 8/10/23 | 8/23/23 | 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. | 12/1/23 | 12/21/23 | 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. | 5/18/23 | 5/22/23 | 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. | 4/13/23 | 4/28/23 | 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. | 12/1/23 | 12/21/23 | 3 - Actual harm | Few |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 4/13/23 | 4/28/23 | 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. | 12/1/23 | 12/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 4/13/23 | 4/28/23 | 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. | 5/18/23 | 5/22/23 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 12/1/23 | 12/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 2/2/24 | 2/16/24 | 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. | 4/13/23 | 4/28/23 | 2 - Minimal harm or potential for actual harm | Many |
Respond appropriately to all alleged violations. | 10/3/22 | 10/18/22 | 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. | 12/2/22 | 12/20/22 | 3 - Actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 6/14/22 | 6/25/22 | 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. | 9/20/22 | 11/11/22 | 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. | 10/24/22 | 11/11/22 | 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. | 10/3/22 | 10/18/22 | 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. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 6/14/22 | 6/25/22 | 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. | 2/24/23 | 3/15/23 | 3 - Actual harm | Few |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 2/24/23 | 3/15/23 | 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. | 12/2/22 | 12/20/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/28/22 | 5/13/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 10/3/22 | 10/18/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 8/11/22 | 8/23/22 | 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. | 10/24/22 | 11/11/22 | 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. | 4/28/22 | 5/13/22 | 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. | 12/2/22 | 12/20/22 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/28/22 | 5/13/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/18/22 | 6/11/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/3/22 | 10/18/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 6/14/22 | 6/24/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 2/24/23 | 3/15/23 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/24/23 | 3/15/23 | 3 - Actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 2/24/23 | 3/15/23 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 2/24/23 | 3/15/23 | 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. | 10/24/22 | 11/11/22 | 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. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 2/24/23 | 3/15/23 | 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. | 10/3/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Some |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 8/26/22 | 9/9/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 10/24/22 | 11/11/22 | 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. | 12/2/22 | 12/20/22 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 2/24/23 | 3/15/23 | 2 - Minimal harm or potential for actual harm | Many |
| This nursing home has not had any infection control inspections in the past 3 years. |