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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 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: | 9/25/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 11/13/24Read the full report (PDF) 9/19/24Read the full report (PDF) 8/20/24Read 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 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) |
---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/8/24 | 5/30/24 | 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. | 9/25/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 5/8/24 | 5/30/24 | 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 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. | 9/25/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 9/25/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/25/24 | 10/18/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/4/24 | 4/17/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 8/20/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/4/24 | 4/17/24 | 3 - Actual harm | Few |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 5/8/24 | 5/30/24 | 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. | 9/25/24 | 10/18/24 | 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) |
---|---|---|---|---|
Implement a program that monitors antibiotic use. | 9/25/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Many |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 9/25/24 | 10/18/24 | 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) |
---|---|---|---|---|
Plan the resident's discharge to meet the resident's goals and needs. | 11/13/24 | 11/14/24 | 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. | 9/25/24 | 10/18/24 | 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 | 8/20/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 9/25/24 | 10/18/24 | 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. | 9/25/24 | 10/18/24 | 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 registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 9/19/24 | 10/8/24 | 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) |
---|---|---|---|---|
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. | 8/20/24 | 9/6/24 | 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. | 9/25/24 | 10/18/24 | 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. | 8/20/24 | 9/6/24 | 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. | 11/13/24 | 11/14/24 | 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) |
---|---|---|---|---|
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | 9/25/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 9/25/24 | 10/18/24 | 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. | 9/25/24 | 11/13/24 | 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. | 9/25/24 | 11/13/24 | 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) |
---|---|---|---|---|
Ensure medication error rates are not 5 percent or greater. | 9/25/24 | 10/18/24 | 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. | 9/25/24 | 10/18/24 | 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. | 9/25/24 | 11/13/24 | 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 rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | 9/25/24 | 10/18/24 | 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. | 9/25/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
No Administration Deficiencies were found during this inspection period. |
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 | 2/10/24Read the full report (PDF) 1/26/24Read the full report (PDF) 8/22/23Read the full report (PDF) 7/31/23Read the full report (PDF) 5/25/23Read 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 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. | 7/31/23 | 8/11/23 | 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. | 1/26/24 | 2/22/24 | 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. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 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. | 4/5/23 | 4/21/23 | 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. | 7/31/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 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) |
---|---|---|---|---|
Ensure a qualified health professional conducts resident assessments. | 8/22/23 | 9/14/23 | 2 - Minimal harm or potential for actual harm | Some |
PASARR screening for Mental disorders or Intellectual Disabilities | 8/22/23 | 9/14/23 | 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. | 2/10/24 | 3/1/24 | 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. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 5/25/23 | 6/9/23 | 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. | 2/10/24 | 3/1/24 | 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. | 8/22/23 | 9/14/23 | 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. | 7/31/23 | 8/11/23 | 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) |
---|---|---|---|---|
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. | 2/10/24 | 3/1/24 | 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. | 7/31/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents have reasonable access to and privacy in their use of communication methods. | 8/22/23 | 9/14/23 | 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) |
---|---|---|---|---|
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. | 8/22/23 | 9/19/23 | 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. | 8/22/23 | 9/14/23 | 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) |
---|---|---|---|---|
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. | 8/22/23 | 9/14/23 | 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) |
---|---|---|---|---|
Put firmly secured handrails on each side of hallways. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 11/1/23 | 2 - Minimal harm or potential for actual harm | Many |
Provide a bathroom in or located near each resident’s room. | 2/10/24 | 3/1/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep all essential equipment working safely. | 7/31/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Few |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 7/27/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 2/22/23Read the full report (PDF) 10/27/22Read the full report (PDF) 7/27/22Read the full report (PDF) 5/11/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in 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. | 7/27/22 | 9/8/22 | 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. | 5/11/22 | 6/3/22 | 3 - Actual harm | Few |
Respond appropriately to all alleged violations. | 5/11/22 | 6/3/22 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/27/22 | 11/30/22 | 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. | 10/27/22 | 11/30/22 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 10/27/22 | 11/30/22 | 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. | 5/11/22 | 6/3/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 5/11/22 | 6/3/22 | 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) |
---|---|---|---|---|
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. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/23/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 7/27/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/8/23 | 3/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 3 - Actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 7/27/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/27/22 | 9/23/22 | 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 staff are vaccinated for COVID-19 | 5/11/22 | 6/3/22 | 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. | 7/27/22 | 9/8/22 | 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 necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Some |
PASARR screening for Mental disorders or Intellectual Disabilities | 7/27/22 | 9/8/22 | 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) |
---|---|---|---|---|
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. | 7/27/22 | 9/23/22 | 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. | 10/27/22 | 12/12/22 | 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. | 2/22/23 | 3/13/23 | 2 - Minimal harm or potential for actual harm | Many |
Post nurse staffing information every day. | 3/8/23 | 3/24/23 | 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. | 3/8/23 | 3/24/23 | 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) |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 1 - Potential for minimal harm | Many |
Ensure that residents are fully informed and understand their health status, care and treatments. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 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) |
---|---|---|---|---|
Provide special eating equipment and utensils for residents who need them and appropriate assistance. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/23/22 | 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) |
---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 7/27/22 | 9/8/22 | 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) |
---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 7/27/22 | 9/8/22 | 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) |
---|---|---|---|---|
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 7/27/22 | 9/8/22 | 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) |
---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/8/24 | 5/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 5/8/24 | 5/30/24 | 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. | 4/4/24 | 4/17/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 8/20/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/4/24 | 4/17/24 | 3 - Actual harm | Few |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 5/8/24 | 5/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Plan the resident's discharge to meet the resident's goals and needs. | 11/13/24 | 11/14/24 | 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 | 8/20/24 | 9/6/24 | 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. | 9/19/24 | 10/8/24 | 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. | 8/20/24 | 9/6/24 | 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. | 8/20/24 | 9/6/24 | 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. | 11/13/24 | 11/14/24 | 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. | 7/31/23 | 8/11/23 | 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. | 1/26/24 | 2/22/24 | 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. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 8/22/23 | 9/14/23 | 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. | 8/22/23 | 9/14/23 | 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. | 4/5/23 | 4/21/23 | 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. | 7/31/23 | 8/11/23 | 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. | 8/22/23 | 9/14/23 | 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. | 2/10/24 | 3/1/24 | 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. | 5/25/23 | 6/9/23 | 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. | 2/10/24 | 3/1/24 | 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. | 8/22/23 | 9/14/23 | 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. | 7/31/23 | 8/11/23 | 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. | 2/10/24 | 3/1/24 | 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. | 7/31/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide a bathroom in or located near each resident’s room. | 2/10/24 | 3/1/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep all essential equipment working safely. | 7/31/23 | 8/11/23 | 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. | 7/27/22 | 9/8/22 | 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. | 5/11/22 | 6/3/22 | 3 - Actual harm | Few |
Respond appropriately to all alleged violations. | 5/11/22 | 6/3/22 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/27/22 | 11/30/22 | 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. | 10/27/22 | 11/30/22 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 10/27/22 | 11/30/22 | 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. | 5/11/22 | 6/3/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 5/11/22 | 6/3/22 | 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. | 7/27/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/8/23 | 3/24/23 | 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. | 7/27/22 | 9/8/22 | 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. | 7/27/22 | 9/8/22 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/27/22 | 9/23/22 | 3 - Actual harm | Few |
Ensure staff are vaccinated for COVID-19 | 5/11/22 | 6/3/22 | 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. | 7/27/22 | 9/23/22 | 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. | 10/27/22 | 12/12/22 | 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. | 2/22/23 | 3/13/23 | 2 - Minimal harm or potential for actual harm | Many |
Post nurse staffing information every day. | 3/8/23 | 3/24/23 | 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. | 3/8/23 | 3/24/23 | 2 - Minimal harm or potential for actual harm | Many |
This nursing home has not had any infection control inspections in the past 3 years. |