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Azria Health Montclair

Inspection Results

Nursing Homes Nebraska Omaha Azria Health Montclair

Azria Health Montclair has been cited for a total of 148 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 Azria Health Montclair.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 194 nursing homes in Nebraska with a total of 7,544 deficiencies resulting in an average of 38.89 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 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:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
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:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Have enough outside ventilation via a window or mechanical ventilation, or both.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
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:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
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:
2023-04-03
Corrected:
2023-04-21
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
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:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Have enough outside ventilation via a window or mechanical ventilation, or both.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2023-04-03
Corrected:
2023-04-21
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-11
Corrected:
2023-02-01
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-11
Corrected:
2023-02-01
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-11
Corrected:
2023-02-01
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-11
Corrected:
2023-02-01
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:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-13
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:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2023-02-01
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2023-02-01
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:
2022-11-14
Corrected:
2022-12-15
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:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
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:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-13
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:
2022-11-14
Corrected:
2022-12-15
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:
2022-11-14
Corrected:
2022-12-15
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2023-02-01
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
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:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2022-12-15
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-11-14
Corrected:
2023-02-01
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:
2022-11-14
Corrected:
2022-12-15
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:
Y
Standard:
N
Survey Date:
2022-07-14
Corrected:
2022-08-28
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-14
Corrected:
2022-08-28
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-14
Corrected:
2022-08-28
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-14
Corrected:
2022-08-28
Ensure staff are vaccinated for COVID-19
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-03-23
Corrected:
2022-05-07
Ensure staff are vaccinated for COVID-19
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-03-23
Corrected:
2022-05-07
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:
2021-10-14
Corrected:
2021-11-25
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:
N
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
2021-10-14
Corrected:
2021-11-25
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:
N
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Allow residents to self-administer drugs if determined clinically appropriate.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
Y
Survey Date:
2021-10-14
Corrected:
2021-11-25
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:
2021-02-22
Corrected:
2021-03-31
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:
N
Survey Date:
2021-02-22
Corrected:
2021-03-31
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-02-22
Corrected:
2021-03-31
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:
N
Survey Date:
2021-02-22
Corrected:
2021-03-31
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-07
Corrected:
2020-10-30
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
N
Survey Date:
2020-06-18
Corrected:
2020-08-03
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-29
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-29
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-29
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-29
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:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
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:
2019-12-11
Corrected:
2020-02-19
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2019-12-11
Corrected:
2020-02-19

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