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Rio Hondo Subacute & Nursing Center

Inspection Results


Nursing Homes California Montebello Rio Hondo Subacute & Nursing Center

Rio Hondo Subacute & Nursing Center has been cited for a total of 224 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 Rio Hondo Subacute & Nursing Center.

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
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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-11-22
Corrected:
2023-12-22

Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-10-25
Corrected:
2023-11-08

Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-10-13
Corrected:
2023-11-03

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:
Y
Standard:
N
Survey Date:
2023-10-11
Corrected:
2023-11-03

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:
Y
Standard:
N
Survey Date:
2023-10-02
Corrected:
2023-10-27

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-10-02
Corrected:
2023-10-27

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:
2023-09-28
Corrected:
2023-10-23

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-09-12
Corrected:
2023-10-11

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:
Y
Standard:
N
Survey Date:
2023-09-12
Corrected:
2023-10-11

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:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-09-09
Corrected:
2023-10-06

Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2023-09-09
Corrected:
2023-10-06

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-09-09
Corrected:
2023-10-06

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:
2023-09-09
Corrected:
2023-10-06

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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-09-09
Corrected:
2023-10-06

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:
2023-09-09
Corrected:
2023-10-06

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-09-09
Corrected:
2023-10-06

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:
2023-07-18
Corrected:
2023-08-14

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:
Y
Standard:
N
Survey Date:
2023-07-07
Corrected:
2023-08-05

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:
2023-06-09
Corrected:
2023-07-06

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-05-30
Corrected:
2023-05-30

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:
Y
Standard:
N
Survey Date:
2023-05-11
Corrected:
2023-06-06

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-05-11
Corrected:
2023-06-06

Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-04-06
Corrected:
2023-04-15

Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-04-06
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
L
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
L
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Make sure that a working call system is available in each resident's bathroom and bathing area.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
L
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
L
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

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:
2023-03-16
Corrected:
2023-04-15

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Make sure that a working call system is available in each resident's bathroom and bathing area.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-03-16
Corrected:
2023-04-15

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-31
Corrected:
2023-02-17

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-31
Corrected:
2023-02-17

Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-20
Corrected:
2023-02-17

Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-20
Corrected:
2023-02-17

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-19
Corrected:
2023-02-09

Make sure that a working call system is available in each resident's bathroom and bathing area.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-19
Corrected:
2023-02-09

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-19
Corrected:
2023-02-09

Make sure that a working call system is available in each resident's bathroom and bathing area.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-19
Corrected:
2023-02-09

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:
Y
Standard:
N
Survey Date:
2023-01-17
Corrected:
2023-02-06

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-04
Corrected:
2023-01-27

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-04
Corrected:
2023-01-27

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:
Y
Standard:
N
Survey Date:
2022-10-04
Corrected:
2022-10-04

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:
Y
Standard:
N
Survey Date:
2022-10-04
Corrected:
2022-10-04

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-13
Corrected:
2022-09-30

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-09-13
Corrected:
2022-09-30

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:
2022-08-27
Corrected:
2022-10-02

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-06-06
Corrected:
2022-06-16

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-06-06
Corrected:
2022-06-16

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-06-06
Corrected:
2022-06-16

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-06-06
Corrected:
2022-06-16

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2022-03-17
Corrected:
2022-04-20

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2022-03-17
Corrected:
2022-04-20

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-03-03
Corrected:
2022-04-15

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-03-03
Corrected:
2022-04-15

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:
Y
Standard:
N
Survey Date:
2022-02-26
Corrected:
2022-04-19

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:
Y
Standard:
N
Survey Date:
2022-02-26
Corrected:
2022-04-19

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:
2022-02-17
Corrected:
2022-04-13

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:
2022-02-17
Corrected:
2022-04-13

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-02-14
Corrected:
2022-03-16

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-02-14
Corrected:
2022-03-16

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-02-07
Corrected:
2022-02-16

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-02-07
Corrected:
2022-02-16

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:
Y
Standard:
N
Survey Date:
2022-01-26
Corrected:
2022-03-02

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:
Y
Standard:
N
Survey Date:
2022-01-26
Corrected:
2022-03-02

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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-30
Corrected:
2022-01-30

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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-30
Corrected:
2022-01-30

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:
J
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-21
Corrected:
2021-08-03

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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-21
Corrected:
2021-08-03

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-21
Corrected:
2021-08-03

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:
J
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-21
Corrected:
2021-08-03

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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-21
Corrected:
2021-08-03

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-21
Corrected:
2021-08-03

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-04-15
Corrected:
2021-04-28

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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-04-15
Corrected:
2021-04-28

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-24
Corrected:
2021-04-05

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-24
Corrected:
2021-04-05

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:
2021-02-24
Corrected:
2021-08-20

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:
2021-02-24
Corrected:
2021-08-20

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-02-05
Corrected:
2021-03-19

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-02-05
Corrected:
2021-03-19

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:
2021-01-28
Corrected:
2021-03-17

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:
2021-01-28
Corrected:
2021-03-17

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:
Y
Standard:
N
Survey Date:
2021-01-15
Corrected:
2021-03-16

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:
Y
Standard:
N
Survey Date:
2021-01-15
Corrected:
2021-03-16

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:
2021-01-07
Corrected:
2021-02-04

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:
2021-01-07
Corrected:
2021-02-04

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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2020-11-25
Corrected:
2021-03-22

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2020-11-18
Corrected:
2020-12-13

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2020-11-02
Corrected:
2020-12-29

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:
N
Standard:
N
Survey Date:
2020-09-25
Corrected:
2020-10-08

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2020-09-25
Corrected:
2020-10-08

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2020-07-28
Corrected:
2020-08-30

Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

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:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

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:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

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:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2020-02-06
Corrected:
2020-03-03

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:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-02-06
Corrected:
2020-03-03

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:
2019-01-28
Corrected:
2019-03-15

Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

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:
2019-01-28
Corrected:
2019-03-15

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-01-28
Corrected:
2019-03-15



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