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Windsor Nursing & Retirement Home

Inspection Results

Nursing Homes Massachusetts South Yarmouth Windsor Nursing & Retirement Home

Windsor Nursing & Retirement Home has been cited for a total of 117 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 Windsor Nursing & Retirement Home.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 367 nursing homes in Massachusetts with a total of 22,497 deficiencies resulting in an average of 61.30 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
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-12
Corrected:
2023-11-22
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-12
Corrected:
2023-11-22
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:
2023-10-12
Corrected:
2023-11-22
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-12
Corrected:
2023-11-22
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:
2023-10-12
Corrected:
2023-11-22
Assist a resident in gaining access to vision and hearing services.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-12
Corrected:
2023-11-22
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-12
Corrected:
2023-11-22
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:
2023-10-12
Corrected:
2023-11-22
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:
2023-10-12
Corrected:
2023-11-22
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:
2023-10-12
Corrected:
2023-11-22
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:
2023-06-01
Corrected:
2023-06-30
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2023-03-13
Corrected:
2023-03-22
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2023-03-13
Corrected:
2023-03-22
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
N
Survey Date:
2023-03-13
Corrected:
2023-03-22
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:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-10-04
Corrected:
2022-10-03
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:
2022-10-04
Corrected:
2022-10-18
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:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-10-04
Corrected:
2022-10-03
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:
2022-10-04
Corrected:
2022-10-18
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:
2021-04-14
Corrected:
2021-06-15
Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-15
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Provide appropriate foot care.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-11
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-15
Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-15
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Provide appropriate foot care.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
2021-04-14
Corrected:
2021-06-01
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:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-11
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-04-14
Corrected:
2021-06-01
Give the resident's representative the ability to exercise the resident's rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Assess the resident when there is a significant change in condition
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Assure that each resident’s assessment is updated at least once every 3 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Provide appropriate foot care.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Give the resident's representative the ability to exercise the resident's rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Assess the resident when there is a significant change in condition
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
Assure that each resident’s assessment is updated at least once every 3 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Provide appropriate foot care.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-08-08
Corrected:
2019-10-07
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:
2019-08-08
Corrected:
2019-10-07
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:
2018-07-06
Corrected:
2018-08-13
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:
G
From Complaint:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13
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:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13
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:
2018-07-06
Corrected:
2018-08-13
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13
Plan the resident's discharge to meet the resident's goals and needs.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-07-06
Corrected:
2018-08-13

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