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| Deficiency Category | Inspection Date: 11/19/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 9/1/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 6/17/22 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: | 11/19/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 11/19/24Read the full report (PDF) 10/15/24Read the full report (PDF) 9/27/24Read the full report (PDF) 8/14/24Read the full report (PDF) 5/30/24Read the full report (PDF) 4/30/24Read 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 Texas: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/30/24 | 6/24/24 | 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 care and assistance to perform activities of daily living for any resident who is unable. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/19/24 | 12/17/24 | 4 - Immediate jeopardy to resident health or safety | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/15/24 | 11/16/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 1/2/25 | 2 - Minimal harm or potential for actual harm | Some | |
Provide activities to meet all resident's needs. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide activities to meet all resident's needs. | 9/27/24 | 2 - Minimal harm or potential for actual harm | Some | |
Provide appropriate foot care. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/14/24 | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 8/14/24 | 9/26/24 | 4 - Immediate jeopardy to resident health or safety | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 4/30/24 | 5/31/24 | 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) |
|---|---|---|---|---|
PASARR screening for Mental disorders or Intellectual Disabilities | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 8/14/24 | 9/26/24 | 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 enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Post nurse staffing information every day. | 8/14/24 | 9/26/24 | 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure residents have reasonable access to and privacy in their use of communication methods. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 8/14/24 | 9/26/24 | 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. | 11/19/24 | 12/17/24 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/14/24 | 9/26/24 | 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 medication error rates are not 5 percent or greater. | 11/19/24 | 12/17/24 | 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. | 1/2/25 | 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. | 11/19/24 | 12/17/24 | 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) |
|---|---|---|---|---|
Make sure that a working call system is available in each resident's bathroom and bathing area. | 8/14/24 | 4 - Immediate jeopardy to resident health or safety | Some | |
Have policies on smoking. | 8/14/24 | 9/26/24 | 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) |
|---|---|---|---|---|
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. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Some |
| Date of last standard health inspection: | 9/1/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 2/29/24Read the full report (PDF) 2/16/24Read the full report (PDF) 1/25/24Read the full report (PDF) 1/17/24Read the full report (PDF) 12/13/23Read the full report (PDF) 10/16/23Read the full report (PDF) 7/27/23Read the full report (PDF) 7/17/23Read the full report (PDF) 6/16/23Read the full report (PDF) 5/28/23Read the full report (PDF) 5/24/23Read the full report (PDF) 5/16/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | 1/17/24Read the full report (PDF) 5/10/23Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Texas: | |
| 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) |
|---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 9/1/23 | 9/15/23 | 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. | 9/1/23 | 9/15/23 | 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 safe and appropriate respiratory care for a resident when needed. | 1/25/24 | 2/25/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 9/1/23 | 9/15/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/9/23 | 8/9/23 | 4 - Immediate jeopardy to resident health or safety | 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. | 5/24/23 | 2 - Minimal harm or potential for actual harm | Few | |
Provide or get specialized rehabilitative services as required for a resident. | 5/16/23 | 6/16/23 | 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. | 2/29/24 | 2/27/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/3/23 | 2 - Minimal harm or potential for actual harm | Few | |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/28/23 | 6/28/23 | 2 - Minimal harm or potential for actual harm | Few |
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. | 6/16/23 | 6/30/23 | 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. | 10/16/23 | 11/16/23 | 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. | 5/28/23 | 6/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 5/3/23 | 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) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/9/23 | 7/14/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Plan the resident's discharge to meet the resident's goals and needs. | 12/13/23 | 1/13/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 6/5/23 | 7/31/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 7/17/23 | 8/7/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 6/16/23 | 6/30/23 | 2 - Minimal harm or potential for actual harm | Some |
Observe each nurse aide's job performance and give regular training. | 9/1/23 | 9/15/23 | 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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 9/1/23 | 9/15/23 | 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. | 2/29/24 | 4/15/24 | 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. | 9/1/23 | 9/15/23 | 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. | 2/16/24 | 3/16/24 | 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. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Many |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 9/1/23 | 9/15/23 | 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) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/27/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 7/27/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 9/1/23 | 9/15/23 | 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) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 1/17/24 | 2/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 6/17/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | No complaint inspections |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 6/23/22Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Texas: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe and appropriate respiratory care for a resident when needed. | 6/17/22 | 6/30/22 | 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 and implement an infection prevention and control program. | 6/17/22 | 6/30/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| No Resident Rights Deficiencies were found during this inspection period. |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 6/17/22 | 6/30/22 | 2 - Minimal harm or potential for actual harm | Some |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration 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) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/30/24 | 6/24/24 | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/19/24 | 12/17/24 | 4 - Immediate jeopardy to resident health or safety | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/15/24 | 11/16/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 1/2/25 | 2 - Minimal harm or potential for actual harm | Some | |
Provide activities to meet all resident's needs. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide activities to meet all resident's needs. | 9/27/24 | 2 - Minimal harm or potential for actual harm | Some | |
Provide appropriate foot care. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/14/24 | 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. | 8/14/24 | 9/26/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide and implement an infection prevention and control program. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 4/30/24 | 5/31/24 | 2 - Minimal harm or potential for actual harm | Some |
PASARR screening for Mental disorders or Intellectual Disabilities | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Post nurse staffing information every day. | 8/14/24 | 9/26/24 | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure residents have reasonable access to and privacy in their use of communication methods. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 8/14/24 | 9/26/24 | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 11/19/24 | 12/17/24 | 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. | 1/2/25 | 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. | 11/19/24 | 12/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 8/14/24 | 4 - Immediate jeopardy to resident health or safety | Some | |
Have policies on smoking. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 8/14/24 | 9/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 9/1/23 | 9/15/23 | 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. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 1/25/24 | 2/25/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 9/1/23 | 9/15/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/9/23 | 8/9/23 | 4 - Immediate jeopardy to resident health or safety | 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. | 5/24/23 | 2 - Minimal harm or potential for actual harm | Few | |
Provide or get specialized rehabilitative services as required for a resident. | 5/16/23 | 6/16/23 | 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. | 2/29/24 | 2/27/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/3/23 | 2 - Minimal harm or potential for actual harm | Few | |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/28/23 | 6/28/23 | 2 - Minimal harm or potential for actual harm | Few |
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. | 6/16/23 | 6/30/23 | 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. | 10/16/23 | 11/16/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 5/28/23 | 6/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 5/3/23 | 2 - Minimal harm or potential for actual harm | Some | |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/1/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/9/23 | 7/14/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Plan the resident's discharge to meet the resident's goals and needs. | 12/13/23 | 1/13/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 6/5/23 | 7/31/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 7/17/23 | 8/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 6/16/23 | 6/30/23 | 2 - Minimal harm or potential for actual harm | Some |
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. | 2/29/24 | 4/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 2/16/24 | 3/16/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/27/23 | 8/11/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 7/27/23 | 8/11/23 | 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. | 1/17/24 | 2/17/24 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |