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Pavilion On Pico Healthcare And Wellness Centre Lp

Inspection Results

Nursing Homes California Los Angeles Pavilion On Pico Healthcare And Wellness Centre Lp

Pavilion On Pico Healthcare And Wellness Centre Lp has been cited for a total of 111 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Pavilion On Pico Healthcare And Wellness Centre Lp.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 1244 nursing homes in California with a total of 104,457 deficiencies resulting in an average of 83.97 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
PASARR screening for Mental disorders or Intellectual Disabilities
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
Assist a resident in gaining access to vision and hearing services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-20
Corrected:
2023-11-09
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-08-18
Corrected:
2023-09-18
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-04-04
Corrected:
2023-04-26
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-04-04
Corrected:
2023-04-26
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-01
Corrected:
2023-03-01
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-01
Corrected:
2023-03-01
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
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.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
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.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-30
Corrected:
2022-12-17
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-10-03
Corrected:
2022-11-03
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-10-03
Corrected:
2022-11-03
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-17
Corrected:
2022-05-31
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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-17
Corrected:
2022-05-31
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-02-19
Corrected:
2022-03-15
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-02-19
Corrected:
2022-03-15
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-08
Corrected:
2021-11-29
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-08
Corrected:
2021-11-29
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-29
Corrected:
2021-08-30
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-14
Corrected:
2021-07-29
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-14
Corrected:
2021-07-29
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-05-31
Corrected:
2021-07-02
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-05-31
Corrected:
2021-07-02
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-05-31
Corrected:
2021-07-02
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-05-31
Corrected:
2021-07-02
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-05-31
Corrected:
2021-07-02
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-05-31
Corrected:
2021-07-02
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-16
Corrected:
2021-04-01
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-16
Corrected:
2021-04-01
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-01-15
Corrected:
2021-03-04
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-01-15
Corrected:
2021-03-04
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2020-08-19
Corrected:
2020-09-03
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Assure that each resident’s assessment is updated at least once every 3 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Assure that each resident’s assessment is updated at least once every 3 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
2020-03-31
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-03-08
Corrected:
Ensure that residents are fully informed and understand their health status, care and treatments.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
2019-05-31
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category:
Environmental Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-04-15
Corrected:

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