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Health Inspection Summary
Decatur Rehab & Health Care CT
136 South Dipper Lane
Decatur, IL 62522
(217) 428-7767
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Deficiency Category
Inspection Date:
9/25/24
Complaint Reporting Period:
4/1/24 - 3/31/25
Inspection Date:
8/22/23
Complaint Reporting Period:
4/1/23 - 3/31/24
Inspection Date:
7/27/22
Complaint Reporting Period:
4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies358
Quality of Life and Care Deficiencies8510
Infection Control Deficiencies212
Resident Assessment and Care Planning Deficiencies563
Nursing and Physician Services Deficiencies145
Resident Rights Deficiencies434
Nutrition and Dietary Deficiencies422
Pharmacy Service Deficiencies315
Environmental Deficiencies241
Administration Deficiencies001

Detailed result for inspection on 9/25/24
Date of last standard health inspection:9/25/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25
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:32
Average number of Health Deficiencies in Illinois:12.2
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

5/8/245/30/24
2 - Minimal harm or potential for actual harm
Some

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

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Respond appropriately to all alleged violations.

5/8/245/30/24
2 - Minimal harm or potential for actual harm
Some
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate 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.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

9/25/2410/18/24
3 - Actual harm
Few

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

4/4/244/17/24
3 - Actual harm
Few

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

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

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

4/4/244/17/24
3 - Actual harm
Few

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

5/8/245/30/24
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.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement a program that monitors antibiotic use.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Many

Develop and implement policies and procedures for flu and pneumonia vaccinations.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

11/13/2411/14/24
2 - Minimal harm or potential for actual harm
Some

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

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

9/25/2410/18/24
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.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

9/19/2410/8/24
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

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

11/13/2411/14/24
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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.

9/25/2411/13/24
2 - Minimal harm or potential for actual harm
Many

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

9/25/2411/13/24
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

9/25/2410/18/24
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.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

9/25/2411/13/24
2 - Minimal harm or potential for actual harm
Many
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Many

Make sure that a working call system is available in each resident's bathroom and bathing area.

9/25/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 8/22/23
Date of last standard health inspection:8/22/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24
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:31
Average number of Health Deficiencies in Illinois:13
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

7/31/238/11/23
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.

1/26/242/22/24
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.

8/22/239/14/23
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.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

8/22/239/14/23
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.

4/5/234/21/23
2 - Minimal harm or potential for actual harm
Some

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

7/31/238/11/23
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few

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

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a qualified health professional conducts resident assessments.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Some

PASARR screening for Mental disorders or Intellectual Disabilities

8/22/239/14/23
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.

2/10/243/1/24
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.

8/22/239/14/23
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.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

5/25/236/9/23
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

7/31/238/11/23
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

7/31/238/11/23
2 - Minimal harm or potential for actual harm
Few

Ensure residents have reasonable access to and privacy in their use of communication methods.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Many
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

8/22/239/19/23
1 - Potential for minimal 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.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Put firmly secured handrails on each side of hallways.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Some

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

8/22/2311/1/23
2 - Minimal harm or potential for actual harm
Many

Provide a bathroom in or located near each resident’s room.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Some

Keep all essential equipment working safely.

7/31/238/11/23
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 7/27/22
Date of last standard health inspection:7/27/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23
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:41
Average number of Health Deficiencies in Illinois:12.5
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

7/27/229/8/22
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.

5/11/226/3/22
3 - Actual harm
Few

Respond appropriately to all alleged violations.

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Some

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

10/27/2211/30/22
2 - Minimal harm or potential for actual harm
Many

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

10/27/2211/30/22
2 - Minimal harm or potential for actual harm
Few

Respond appropriately to all alleged violations.

10/27/2211/30/22
4 - Immediate jeopardy to resident health or safety
Many

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

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Some
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate 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.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

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

7/27/229/8/22
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.

7/27/229/23/22
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

3/8/233/24/23
2 - Minimal harm or potential for actual harm
Few

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

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

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

7/27/229/8/22
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.

7/27/229/8/22
3 - Actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/27/229/23/22
3 - Actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure staff are vaccinated for COVID-19

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Many

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Many
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

7/27/229/8/22
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.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some

PASARR screening for Mental disorders or Intellectual Disabilities

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

7/27/229/23/22
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

10/27/2212/12/22
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

2/22/233/13/23
2 - Minimal harm or potential for actual harm
Many

Post nurse staffing information every day.

3/8/233/24/23
1 - Potential for minimal harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

3/8/233/24/23
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to organize and participate in resident/family groups in the facility.

7/27/229/8/22
1 - Potential for minimal harm
Many

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

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some

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

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

7/27/229/8/22
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.

7/27/229/23/22
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some

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.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some

Ensure each resident’s drug regimen must be free from unnecessary drugs.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Many
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

5/8/245/30/24
2 - Minimal harm or potential for actual harm
Some

Respond appropriately to all alleged violations.

5/8/245/30/24
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.

4/4/244/17/24
3 - Actual harm
Few

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

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

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

4/4/244/17/24
3 - Actual harm
Few

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

5/8/245/30/24
2 - Minimal harm or potential for actual harm
Some

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

11/13/2411/14/24
2 - Minimal harm or potential for actual harm
Some

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

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

9/19/2410/8/24
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.

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

8/20/249/6/24
2 - Minimal harm or potential for actual harm
Few

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

11/13/2411/14/24
2 - Minimal harm or potential for actual harm
Some

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

7/31/238/11/23
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.

1/26/242/22/24
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.

8/22/239/14/23
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.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

8/22/239/14/23
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.

8/22/239/14/23
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.

4/5/234/21/23
2 - Minimal harm or potential for actual harm
Some

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

7/31/238/11/23
2 - Minimal harm or potential for actual harm
Few

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

8/22/239/14/23
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.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Few

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

5/25/236/9/23
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

8/22/239/14/23
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

7/31/238/11/23
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.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

7/31/238/11/23
2 - Minimal harm or potential for actual harm
Few

Provide a bathroom in or located near each resident’s room.

2/10/243/1/24
2 - Minimal harm or potential for actual harm
Some

Keep all essential equipment working safely.

7/31/238/11/23
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.

7/27/229/8/22
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.

5/11/226/3/22
3 - Actual harm
Few

Respond appropriately to all alleged violations.

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Some

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

10/27/2211/30/22
2 - Minimal harm or potential for actual harm
Many

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

10/27/2211/30/22
2 - Minimal harm or potential for actual harm
Few

Respond appropriately to all alleged violations.

10/27/2211/30/22
4 - Immediate jeopardy to resident health or safety
Many

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

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

5/11/226/3/22
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.

7/27/229/8/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

3/8/233/24/23
2 - Minimal harm or potential for actual harm
Few

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

7/27/229/8/22
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.

7/27/229/8/22
3 - Actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/27/229/23/22
3 - Actual harm
Few

Ensure staff are vaccinated for COVID-19

5/11/226/3/22
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

7/27/229/23/22
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

10/27/2212/12/22
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

2/22/233/13/23
2 - Minimal harm or potential for actual harm
Many

Post nurse staffing information every day.

3/8/233/24/23
1 - Potential for minimal harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

3/8/233/24/23
2 - Minimal harm or potential for actual harm
Many
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
Medicare
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