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🔎 Loft Rehabilitation And Nursing

Inspection Results


Inspection Overview

Loft Rehabilitation And Nursing has been cited for a total of 129 deficiencies since we began saving each survey.

In Illinois, the average facility has **50.07 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2025-03-26
Correction Date: 2025-04-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-11-01
Correction Date: 2024-11-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-09-25
Correction Date: 2024-10-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-09-01
Correction Date: 2024-11-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-08-01
Correction Date: 2024-11-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: F

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2024-08-01
Correction Date: 2024-08-31
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-07-02
Correction Date: 2024-11-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-06-03
Correction Date: 2024-06-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-06-03
Correction Date: 2024-06-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2024-06-03
Correction Date: 2024-07-09
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2024-06-03
Correction Date: 2024-07-09
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-04-30
Correction Date: 2024-05-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2024-04-30
Correction Date: 2024-05-18
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-04-03
Correction Date: 2024-04-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.

Survey Date: 2024-01-08
Correction Date: 2024-01-25
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2024-01-08
Correction Date: 2024-01-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: F

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2024-01-08
Correction Date: 2024-01-25
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: K

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-07-28
Correction Date: 2023-08-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-05-26
Correction Date: 2023-06-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-05-26
Correction Date: 2023-06-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide care or services that was trauma informed and/or culturally competent.

Survey Date: 2023-05-26
Correction Date: 2023-06-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-05-16
Correction Date: 2023-06-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2022-12-12
Correction Date: 2022-12-16
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2022-07-16
Correction Date: 2022-08-05
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-07-16
Correction Date: 2022-08-05
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Survey Date: 2022-07-16
Correction Date: 2022-08-05
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2022-04-14
Correction Date: 2022-05-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-04-14
Correction Date: 2022-04-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: G

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-04-14
Correction Date: 2022-04-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: K

Respond appropriately to all alleged violations.

Survey Date: 2022-04-14
Correction Date: 2022-04-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-04-14
Correction Date: 2022-05-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-04-14
Correction Date: 2022-05-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Survey Date: 2022-04-14
Correction Date: 2022-05-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2022-04-14
Correction Date: 2022-05-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-04-14
Correction Date: 2022-05-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Survey Date: 2022-04-14
Correction Date: 2022-04-15
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2022-04-14
Correction Date: 2022-05-06
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-03-20
Correction Date: 2022-03-25
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2022-03-10
Correction Date: 2022-03-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-03-10
Correction Date: 2022-03-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-03-10
Correction Date: 2022-03-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-03-10
Correction Date: 2022-03-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2022-01-16
Correction Date: 2022-02-02
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-01-16
Correction Date: 2022-02-02
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2022-01-06
Correction Date: 2022-01-23
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2022-01-06
Correction Date: 2022-01-23
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-01-06
Correction Date: 2022-01-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-01-06
Correction Date: 2022-01-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to manage his or her financial affairs.

Survey Date: 2021-12-21
Correction Date: 2022-01-13
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: H

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2021-12-21
Correction Date: 2022-01-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: F

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-12-21
Correction Date: 2022-01-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: H

Respond appropriately to all alleged violations.

Survey Date: 2021-12-21
Correction Date: 2022-01-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-11-24
Correction Date: 2021-12-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-11-24
Correction Date: 2021-12-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Survey Date: 2021-11-24
Correction Date: 2021-12-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2021-11-12
Correction Date: 2021-12-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-11-08
Correction Date: 2021-12-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2021-11-08
Correction Date: 2021-12-10
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2021-11-08
Correction Date: 2021-12-10
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-09-29
Correction Date: 2021-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-09-21
Correction Date: 2021-10-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-09-21
Correction Date: 2021-10-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

Respond appropriately to all alleged violations.

Survey Date: 2021-09-21
Correction Date: 2021-10-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2021-09-21
Correction Date: 2021-10-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-07-21
Correction Date: 2021-07-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-07-09
Correction Date: 2021-07-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2021-04-14
Correction Date: 2021-05-04
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-02-18
Correction Date: 2021-03-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-02-18
Correction Date: 2021-03-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2021-02-18
Correction Date: 2021-03-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-02-18
Correction Date: 2021-03-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-18
Correction Date: 2021-03-12
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2021-02-18
Correction Date: 2021-03-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-01-09
Correction Date: 2021-02-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2020-12-11
Correction Date: 2021-01-04
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-08-14
Correction Date: 2020-08-26
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-04-11
Correction Date: 2019-09-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

The resident has the right to receive notices in a format and a language he or she understands.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-04-11
Correction Date: 2019-09-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-04-11
Correction Date: 2019-09-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-04-11
Correction Date: 2019-09-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-04-11
Correction Date: 2019-09-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2019-04-11
Correction Date: 2019-07-10
Category: Nursing and Physician Services Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**