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Deficiency Category | Inspection Date: 9/10/24 Complaint Reporting Period: 5/1/24 - 4/30/25 | Inspection Date: 10/14/22 Complaint Reporting Period: 5/1/23 - 4/30/24 | Inspection Date: 9/11/19 Complaint Reporting Period: 5/1/22 - 4/30/23 |
---|---|---|---|
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: | 9/10/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25 | 9/10/24Read the full report (PDF) |
Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Maryland: | |
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. | 9/10/24 | 10/18/24 | 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. | 9/10/24 | 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) |
---|---|---|---|---|
Provide routine and 24-hour emergency dental care for each resident. | 3/4/25 | 4/2/25 | 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. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide or get specialized rehabilitative services as required for a resident. | 3/4/25 | 4/2/25 | 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. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 9/10/24 | 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) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 9/10/24 | 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) |
---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 9/10/24 | 10/18/24 | 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 | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 3/4/25 | 4/2/25 | 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. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure medication error rates are not 5 percent or greater. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Date of last standard health inspection: | 10/14/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24 | No complaint inspections |
Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Maryland: | |
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 the wrongful use of the resident's belongings or money. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 11/21/22 | 3 - Actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide activities to meet all resident's needs. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 10/14/22 | 1/13/23 | 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. | 10/14/22 | 11/21/22 | 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) |
---|---|---|---|---|
Assure that each resident’s assessment is updated at least once every 3 months. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/14/22 | 1/13/23 | 2 - Minimal harm or potential for actual harm | Some |
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide or arrange emergency care by a doctor 24 hours a day. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Post nurse staffing information every day. | 10/14/22 | 1/13/23 | 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) |
---|---|---|---|---|
The resident has the right to receive notices in a format and a language he or she understands. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | 10/14/22 | 1/13/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 1/13/23 | 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. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 10/14/22 | 1/13/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 10/14/22 | 11/21/22 | 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) |
---|---|---|---|---|
Put firmly secured handrails on each side of hallways. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 10/14/22 | 11/21/22 | 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) |
---|---|---|---|---|
Have a plan that describes the process for conducting QAPI and QAA activities. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Date of last standard health inspection: | 9/11/19Read the full report (PDF) |
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23 | 10/14/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Maryland: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide safe, appropriate pain management for a resident who requires such services. | 9/11/19 | 10/25/19 | 3 - Actual harm | Few |
Provide or obtain dental services for each resident. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/11/19 | 10/25/19 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
No Infection Control 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) |
---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 9/11/19 | 10/25/19 | 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. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 9/11/19 | 10/25/19 | 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. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 9/11/19 | 10/25/19 | 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. | 9/11/19 | 10/25/19 | 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. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 9/11/19 | 10/25/19 | 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. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | 9/11/19 | 10/25/19 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 9/10/24 | 10/18/24 | 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. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide routine and 24-hour emergency dental care for each resident. | 3/4/25 | 4/2/25 | 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. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide or get specialized rehabilitative services as required for a resident. | 3/4/25 | 4/2/25 | 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. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 9/10/24 | 10/18/24 | 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 | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/10/24 | 10/18/24 | 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. | 3/4/25 | 4/2/25 | 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. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure medication error rates are not 5 percent or greater. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | 3/4/25 | 4/2/25 | 2 - Minimal harm or potential for actual harm | Few |
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Some |
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | 9/10/24 | 10/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 11/21/22 | 3 - Actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 10/14/22 | 1/13/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/14/22 | 1/13/23 | 2 - Minimal harm or potential for actual harm | Some |
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Post nurse staffing information every day. | 10/14/22 | 1/13/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 10/14/22 | 11/21/22 | 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. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Many |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 10/14/22 | 11/21/22 | 2 - Minimal harm or potential for actual harm | Some |
This nursing home has not had any infection control inspections in the past 3 years. |