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| Deficiency Category | Inspection Date: 10/10/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 10/17/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 7/27/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 10/10/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 11/13/24Read the full report (PDF) 8/27/24Read the full report (PDF) 6/19/24Read 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 Wisconsin: | |
| 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) |
|---|---|---|---|---|
Respond appropriately to all alleged violations. | 10/10/24 | 11/4/24 | 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. | 10/10/24 | 11/4/24 | 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) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/13/24 | 12/6/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 6/19/24 | 8/1/24 | 3 - 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. | 10/10/24 | 11/4/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 6/19/24 | 7/15/24 | 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. | 8/27/24 | 9/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate foot care. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/10/24 | 11/4/24 | 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. | 6/19/24 | 7/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 6/19/24 | 7/15/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
PASARR screening for Mental disorders or Intellectual Disabilities | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 10/10/24 | 11/4/24 | 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) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 6/19/24 | 7/15/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | 10/10/24 | 11/4/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | 6/19/24 | 7/16/24 | 3 - Actual harm | Few |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | 6/19/24 | 7/15/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep residents' personal and medical records private and confidential. | 6/19/24 | 7/15/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 10/10/24 | 11/4/24 | 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. | 6/19/24 | 7/15/24 | 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. | 10/10/24 | 11/4/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 10/17/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 12/21/23Read the full report (PDF) 8/30/23Read 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 Wisconsin: | |
| 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. | 3/7/24 | 4/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 5/4/23 | 5/31/23 | 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. | 5/4/23 | 5/31/23 | 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 1/4/24 | 1/19/24 | 3 - Actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 10/17/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/21/23 | 1/19/24 | 4 - Immediate jeopardy to resident health or safety | 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. | 10/17/23 | 11/16/23 | 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. | 10/17/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/4/23 | 5/31/23 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 5/4/23 | 5/31/23 | 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. | 5/4/23 | 5/31/23 | 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) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 10/17/23 | 11/16/23 | 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. | 8/30/23 | 9/12/23 | 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. | 12/21/23 | 1/19/24 | 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 the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 5/4/23 | 5/31/23 | 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) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 3/7/24 | 4/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 10/17/23 | 11/16/23 | 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. | 5/4/23 | 5/31/23 | 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. | 10/17/23 | 11/16/23 | 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. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 10/17/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 8/30/23 | 9/12/23 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 1/4/24 | 1/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Dispose of garbage and refuse properly. | 10/17/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/17/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Many |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 12/21/23 | 1/19/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure 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. | 6/7/23 | 7/3/23 | 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. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 6/7/23 | 7/3/23 | 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) |
|---|---|---|---|---|
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | 10/17/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 7/27/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 3/23/23Read the full report (PDF) 9/22/22Read the full report (PDF) 7/27/22Read the full report (PDF) 4/27/22Read 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 Wisconsin: | |
| 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) |
|---|---|---|---|---|
Respond appropriately to all alleged violations. | 7/27/22 | 8/24/22 | 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. | 7/27/22 | 11/1/22 | 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. | 7/27/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 7/27/22 | 8/24/22 | 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. | 9/22/22 | 11/1/22 | 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 care and assistance to perform activities of daily living for any resident who is unable. | 3/23/23 | 4/17/23 | 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. | 4/27/22 | 5/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/27/22 | 11/1/22 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/22/22 | 11/1/22 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure the activities program is directed by a qualified professional. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/27/22 | 6/30/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/27/22 | 6/30/22 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/22/22 | 11/1/22 | 3 - Actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 9/22/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | 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. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Many |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Many |
Implement a program that monitors antibiotic use. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 7/27/22 | 8/24/22 | 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) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 3/23/23 | 4/17/23 | 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. | 9/22/22 | 11/1/22 | 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. | 7/27/22 | 8/24/22 | 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 | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | 9/22/22 | 11/1/22 | 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) |
|---|---|---|---|---|
Post nurse staffing information every day. | 3/23/23 | 4/17/23 | 1 - Potential for minimal harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | 3/23/23 | 4/17/23 | 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. | 4/27/22 | 5/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | 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. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 9/22/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Allow residents to self-administer drugs if determined clinically appropriate. | 7/27/22 | 8/24/22 | 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. | 7/27/22 | 11/1/22 | 3 - Actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 9/22/22 | 11/1/22 | 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. | 7/27/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 7/27/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/27/22 | 8/24/22 | 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 medication error rates are not 5 percent or greater. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 9/22/22 | 11/1/22 | 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. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 7/27/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Many |
Help the resident with transportation to and from laboratory services outside of the facility. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Help the resident with transportation to and from laboratory services outside of the facility. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 9/22/22 | 11/1/22 | 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/13/24 | 12/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 6/19/24 | 8/1/24 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 6/19/24 | 7/15/24 | 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. | 8/27/24 | 9/18/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/19/24 | 7/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 6/19/24 | 7/15/24 | 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. | 6/19/24 | 7/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | 6/19/24 | 7/16/24 | 3 - Actual harm | Few |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | 6/19/24 | 7/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 6/19/24 | 7/15/24 | 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. | 6/19/24 | 7/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 3/7/24 | 4/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 5/4/23 | 5/31/23 | 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. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 1/4/24 | 1/19/24 | 3 - Actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/21/23 | 1/19/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/4/23 | 5/31/23 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 5/4/23 | 5/31/23 | 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. | 5/4/23 | 5/31/23 | 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. | 8/30/23 | 9/12/23 | 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. | 12/21/23 | 1/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Some |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 3/7/24 | 4/1/24 | 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. | 5/4/23 | 5/31/23 | 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. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 8/30/23 | 9/12/23 | 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. | 1/4/24 | 1/19/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 5/4/23 | 5/31/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 12/21/23 | 1/19/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 6/7/23 | 7/3/23 | 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. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 7/27/22 | 8/24/22 | 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. | 7/27/22 | 11/1/22 | 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. | 7/27/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 7/27/22 | 8/24/22 | 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. | 9/22/22 | 11/1/22 | 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. | 3/23/23 | 4/17/23 | 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. | 4/27/22 | 5/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/27/22 | 11/1/22 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/22/22 | 11/1/22 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure the activities program is directed by a qualified professional. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/27/22 | 6/30/22 | 3 - Actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/27/22 | 6/30/22 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/22/22 | 11/1/22 | 3 - Actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 9/22/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide and implement an infection prevention and control program. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Many |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Many |
Implement a program that monitors antibiotic use. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 3/23/23 | 4/17/23 | 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. | 9/22/22 | 11/1/22 | 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. | 7/27/22 | 8/24/22 | 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 | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Post nurse staffing information every day. | 3/23/23 | 4/17/23 | 1 - Potential for minimal harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | 3/23/23 | 4/17/23 | 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. | 4/27/22 | 5/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | 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. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 9/22/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 7/27/22 | 11/1/22 | 3 - Actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 9/22/22 | 11/1/22 | 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. | 7/27/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 7/27/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure medication error rates are not 5 percent or greater. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 3/23/23 | 4/17/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 9/22/22 | 11/1/22 | 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. | 7/27/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 7/27/22 | 11/1/22 | 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. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 3/23/23 | 4/17/23 | 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. | 7/27/22 | 8/24/22 | 2 - Minimal harm or potential for actual harm | Many |
Help the resident with transportation to and from laboratory services outside of the facility. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Some |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 9/22/22 | 11/1/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 9/22/22 | 11/1/22 | 2 - Minimal harm or potential for actual harm | Many |
| This nursing home has not had any infection control inspections in the past 3 years. |