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Health Inspection Summary
Ellicott City Healthcare Center
3000 North Ridge Road
Ellicott City, MD 21043
(410) 461-7577
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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 Deficiencies240
Quality of Life and Care Deficiencies1236
Infection Control Deficiencies210
Resident Assessment and Care Planning Deficiencies875
Nursing and Physician Services Deficiencies042
Resident Rights Deficiencies787
Nutrition and Dietary Deficiencies001
Pharmacy Service Deficiencies313
Environmental Deficiencies020
Administration Deficiencies341

Detailed result for inspection on 9/10/24
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
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:37
Average number of Health Deficiencies in Maryland:19.3
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.

9/10/2410/18/24
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.

9/10/2410/18/24
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)

Provide routine and 24-hour emergency dental care for each resident.

3/4/254/2/25
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.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

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

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

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

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

Provide or get specialized rehabilitative services as required for a resident.

3/4/254/2/25
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide activities to meet all resident's needs.

9/10/2410/18/24
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.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

9/10/2410/18/24
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)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

3/4/254/2/25
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.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

9/10/2410/18/24
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.

9/10/2410/18/24
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

9/10/2410/18/24
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
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.

3/4/254/2/25
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.

3/4/254/2/25
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.

9/10/2410/18/24
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
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 each resident’s drug regimen must be free from unnecessary drugs.

3/4/254/2/25
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some

Ensure medication error rates are not 5 percent or greater.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
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)

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.

3/4/254/2/25
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 10/14/22
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:34
Average number of Health Deficiencies in Maryland:14.5
Average number of Health Deficiencies in the United States:9.5
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 the wrongful use of the resident's belongings or money.

10/14/2211/21/22
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.

10/14/2211/21/22
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.

10/14/2211/21/22
3 - Actual harm
Few

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

10/14/2211/21/22
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)

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

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Some

Provide activities to meet all resident's needs.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few

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

10/14/221/13/23
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.

10/14/2211/21/22
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)

Assure that each resident’s assessment is updated at least once every 3 months.

10/14/2211/21/22
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

10/14/2211/21/22
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

10/14/2211/21/22
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.

10/14/221/13/23
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.

10/14/2211/21/22
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)

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Some

Provide or arrange emergency care by a doctor 24 hours a day.

10/14/2211/21/22
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Some

Post nurse staffing information every day.

10/14/221/13/23
2 - Minimal harm or potential for actual harm
Few
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)

The resident has the right to receive notices in a format and a language he or she understands.

10/14/2211/21/22
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.

10/14/221/13/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

10/14/2211/21/22
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.

10/14/2211/21/22
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.

10/14/221/13/23
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

10/14/221/13/23
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
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 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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few
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.

10/14/2211/21/22
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Many
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 a plan that describes the process for conducting QAPI and QAA activities.

10/14/2211/21/22
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.

10/14/2211/21/22
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.

10/14/2211/21/22
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

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Some

Detailed result for inspection on 9/11/19
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
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:25
Average number of Health Deficiencies in Maryland:12.1
Average number of Health Deficiencies in the United States:8.8
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
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 safe, appropriate pain management for a resident who requires such services.

9/11/1910/25/19
3 - Actual harm
Few

Provide or obtain dental services for each resident.

9/11/1910/25/19
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.

9/11/1910/25/19
4 - Immediate jeopardy to resident health or safety
Few

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

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

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

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

Provide activities to meet all resident's needs.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
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)

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

9/11/1910/25/19
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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

9/11/1910/25/19
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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Some
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)

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

9/11/1910/25/19
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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few
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)

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

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

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

9/11/1910/25/19
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.

9/11/1910/25/19
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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

9/11/1910/25/19
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.

9/11/1910/25/19
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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few
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 each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few
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 a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few

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

9/11/1910/25/19
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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
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)

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.

9/11/1910/25/19
2 - Minimal harm or potential for actual harm
Few
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide routine and 24-hour emergency dental care for each resident.

3/4/254/2/25
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.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

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

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

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

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

Provide or get specialized rehabilitative services as required for a resident.

3/4/254/2/25
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide activities to meet all resident's needs.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

9/10/2410/18/24
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.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

3/4/254/2/25
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.

3/4/254/2/25
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

9/10/2410/18/24
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.

9/10/2410/18/24
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

9/10/2410/18/24
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.

9/10/2410/18/24
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.

9/10/2410/18/24
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.

3/4/254/2/25
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.

3/4/254/2/25
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.

9/10/2410/18/24
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

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

3/4/254/2/25
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Some

Ensure medication error rates are not 5 percent or greater.

9/10/2410/18/24
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.

3/4/254/2/25
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.

9/10/2410/18/24
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.

9/10/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Protect each resident from the wrongful use of the resident's belongings or money.

10/14/2211/21/22
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.

10/14/2211/21/22
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.

10/14/2211/21/22
3 - Actual harm
Few

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

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few

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

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Some

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

10/14/221/13/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

10/14/2211/21/22
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.

10/14/221/13/23
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Few

Post nurse staffing information every day.

10/14/221/13/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

10/14/2211/21/22
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.

10/14/2211/21/22
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.

10/14/2211/21/22
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.

10/14/2211/21/22
2 - Minimal harm or potential for actual harm
Some
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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