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| Deficiency Category | Inspection Date: 10/2/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 10/12/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 8/2/22 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: | 10/2/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 12/23/24Read the full report (PDF) 10/2/24Read the full report (PDF) 7/30/24Read the full report (PDF) 6/17/24Read 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 Michigan: | |
| 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. | 6/17/24 | 7/8/24 | 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. | 5/8/24 | 6/6/24 | 3 - Actual harm | Few |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 12/23/24 | 12/23/24 | 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. | 12/23/24 | 12/2/24 | 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) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/17/24 | 7/8/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/2/24 | 10/25/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/8/24 | 6/4/24 | 3 - Actual harm | Few |
Provide or obtain dental services for each resident. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/30/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 7/30/24 | 8/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate foot care. | 7/30/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 5/8/24 | 6/4/24 | 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. | 5/8/24 | 6/4/24 | 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. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 5/8/24 | 6/4/24 | 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. | 10/2/24 | 10/25/24 | 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) |
|---|---|---|---|---|
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 10/2/24 | 10/25/24 | 1 - Potential for minimal harm | Many |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 7/30/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 12/23/24 | 1/3/25 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 10/2/24 | 10/25/24 | 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. | 10/2/24 | 10/25/24 | 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. | 6/17/24 | 7/8/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 5/8/24 | 6/4/24 | 1 - Potential for minimal harm | Many |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/2/24 | 10/25/24 | 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. | 10/2/24 | 10/25/24 | 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. | 10/2/24 | 10/25/24 | 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) |
|---|---|---|---|---|
Hire a qualified full-time social worker in a facility with more than 120 beds. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 10/12/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 12/20/23Read the full report (PDF) 10/12/23Read 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 Michigan: | |
| 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) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/20/23 | 1/5/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 10/12/23 | 11/6/23 | 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) |
|---|---|---|---|---|
Implement a program that monitors antibiotic use. | 10/12/23 | 11/6/23 | 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 services provided by the nursing facility meet professional standards of quality. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/12/23 | 11/6/23 | 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. | 10/12/23 | 11/6/23 | 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 the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | 10/12/23 | 11/6/23 | 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) |
|---|---|---|---|---|
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 10/12/23 | 11/6/23 | 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) |
|---|---|---|---|---|
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. | 10/12/23 | 11/6/23 | 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) |
|---|---|---|---|---|
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide timely, quality laboratory services/tests to meet the needs of residents. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 8/2/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 3/23/23Read the full report (PDF) 10/4/22Read the full report (PDF) 5/19/22Read 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 Michigan: | |
| 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. | 8/2/22 | 8/29/22 | 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. | 4/6/22 | 4/27/22 | 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 8/2/22 | 8/29/22 | 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. | 4/6/22 | 4/27/22 | 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. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/4/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/19/22 | 6/6/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 8/2/22 | 8/29/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 8/2/22 | 8/29/22 | 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) |
|---|---|---|---|---|
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Perform COVID19 testing on residents and staff. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide and implement an infection prevention and control program. | 8/2/22 | 10/3/22 | 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) |
|---|---|---|---|---|
Ensure services provided by the nursing facility meet professional standards of quality. | 3/23/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
PASARR screening for Mental disorders or Intellectual Disabilities | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 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. | 4/6/22 | 4/27/22 | 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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to manage his or her financial affairs. | 8/2/22 | 8/29/22 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Dispose of garbage and refuse properly. | 8/2/22 | 8/29/22 | 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 a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 8/2/22 | 8/29/22 | 3 - Actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 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) |
|---|---|---|---|---|
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 8/2/22 | 8/29/22 | 1 - Potential for minimal harm | Many |
Hire a qualified full-time social worker in a facility with more than 120 beds. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 8/2/22 | 8/29/22 | 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. | 6/17/24 | 7/8/24 | 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. | 5/8/24 | 6/6/24 | 3 - Actual harm | Few |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 12/23/24 | 12/23/24 | 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. | 12/23/24 | 12/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/17/24 | 7/8/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/2/24 | 10/25/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/8/24 | 6/4/24 | 3 - Actual harm | Few |
Provide or obtain dental services for each resident. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/30/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 7/30/24 | 8/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate foot care. | 7/30/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 5/8/24 | 6/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 7/30/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are fully informed and understand their health status, care and treatments. | 12/23/24 | 1/3/25 | 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. | 10/2/24 | 10/25/24 | 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. | 6/17/24 | 7/8/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 5/8/24 | 6/4/24 | 1 - Potential for minimal harm | Many |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 10/2/24 | 10/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/20/23 | 1/5/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/12/23 | 11/6/23 | 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. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely, quality laboratory services/tests to meet the needs of residents. | 10/12/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 8/2/22 | 8/29/22 | 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. | 4/6/22 | 4/27/22 | 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. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 8/2/22 | 8/29/22 | 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. | 4/6/22 | 4/27/22 | 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. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/4/22 | 10/18/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/19/22 | 6/6/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 8/2/22 | 8/29/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Perform COVID19 testing on residents and staff. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide and implement an infection prevention and control program. | 8/2/22 | 10/3/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure services provided by the nursing facility meet professional standards of quality. | 3/23/23 | 4/20/23 | 2 - Minimal harm or potential for actual harm | Few |
PASARR screening for Mental disorders or Intellectual Disabilities | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 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. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/6/22 | 4/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to manage his or her financial affairs. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Dispose of garbage and refuse properly. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 8/2/22 | 8/29/22 | 3 - Actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 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. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Some |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 8/2/22 | 8/29/22 | 1 - Potential for minimal harm | Many |
Hire a qualified full-time social worker in a facility with more than 120 beds. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 8/2/22 | 8/29/22 | 2 - Minimal harm or potential for actual harm | Many |
| This nursing home has not had any infection control inspections in the past 3 years. |