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Mission Point Nsg & Phy Rehab Ctr Of Beverly Hills

Inspection Results

Nursing Homes Michigan Beverly Hills Mission Point Nsg & Phy Rehab Ctr Of Beverly Hills

Mission Point Nsg & Phy Rehab Ctr Of Beverly Hills has been cited for a total of 214 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 Mission Point Nsg & Phy Rehab Ctr Of Beverly Hills.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 440 nursing homes in Michigan with a total of 33,399 deficiencies resulting in an average of 75.91 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 a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
2023-10-26
Corrected:
2023-12-11
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-10-26
Corrected:
2023-12-11
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-08-03
Corrected:
2023-08-24
Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-08-03
Corrected:
2023-08-24
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:
Y
Standard:
N
Survey Date:
2023-08-03
Corrected:
2023-08-24
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-08-03
Corrected:
2023-08-24
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
H
From Complaint:
Y
Standard:
N
Survey Date:
2023-07-21
Corrected:
2023-08-24
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
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:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-24
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:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
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:
K
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-08-30
Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
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:
2023-06-09
Corrected:
2023-07-06
Prepare residents for a safe transfer or discharge from the nursing home.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
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:
2023-06-09
Corrected:
2023-07-06
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
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:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-24
Provide appropriate colostomy, urostomy, or ileostomy 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:
2023-06-09
Corrected:
2023-07-06
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-06
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-09
Corrected:
2023-07-24
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-11-18
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
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:
J
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Assure that each resident’s assessment is updated at least once every 3 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
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:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
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:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-11-18
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Have a plan that describes the process for conducting QAPI and QAA activities.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Ensure staff are vaccinated for COVID-19
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
Y
Standard:
Y
Survey Date:
2022-09-06
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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-11-18
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
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:
J
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Assure that each resident’s assessment is updated at least once every 3 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
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:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
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:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-10-04
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
2022-09-06
Corrected:
2022-11-18
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Have a plan that describes the process for conducting QAPI and QAA activities.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Ensure staff are vaccinated for COVID-19
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
Y
Standard:
Y
Survey Date:
2022-09-06
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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-11-18
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-09-06
Corrected:
2022-10-04
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:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
2022-05-05
Corrected:
2022-06-01
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:
2022-05-05
Corrected:
2022-06-01
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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Employ staff that are licensed, certified, or registered in accordance with state laws.
Category:
Administration Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-07-13
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
L
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-07-13
Ensure staff are vaccinated for COVID-19
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
2022-05-05
Corrected:
2022-06-01
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:
2022-05-05
Corrected:
2022-06-01
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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Employ staff that are licensed, certified, or registered in accordance with state laws.
Category:
Administration Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-07-13
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
L
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-07-13
Ensure staff are vaccinated for COVID-19
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-05-05
Corrected:
2022-06-01
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:
2021-09-01
Corrected:
2021-09-15
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-01
Corrected:
2021-09-15
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:
2021-09-01
Corrected:
2021-09-15
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-01
Corrected:
2021-09-15
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-08-03
Corrected:
2021-08-23
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-08-03
Corrected:
2021-08-23
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:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-09-15
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-09-15
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
2021-06-17
Corrected:
2021-07-20
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:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-20
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:
Y
Standard:
N
Survey Date:
2021-05-26
Corrected:
2021-06-17
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:
2021-05-26
Corrected:
2021-06-17
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:
Y
Standard:
N
Survey Date:
2021-05-26
Corrected:
2021-06-17
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:
2021-05-26
Corrected:
2021-06-17
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:
2020-09-28
Corrected:
2020-09-29
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
L
From Complaint:
N
Standard:
N
Survey Date:
2020-07-29
Corrected:
2020-08-25
Ensure that residents are fully informed and understand their health status, care and treatments.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2020-07-28
Corrected:
2020-08-14
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:
2020-07-28
Corrected:
2020-08-14
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:
2020-07-28
Corrected:
2020-08-14
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:
Y
Standard:
N
Survey Date:
2020-07-28
Corrected:
2020-08-14
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2020-07-28
Corrected:
2020-08-14
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
Provide or get specialized rehabilitative services as required for a resident.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
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:
2019-05-15
Corrected:
2019-06-21
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21
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:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-05-15
Corrected:
2019-06-21

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