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Infinity Park Post-acute And Rehabilitation Center

Inspection Results


Nursing Homes Kansas Overland Park Infinity Park Post-acute And Rehabilitation Center

Infinity Park Post-acute And Rehabilitation Center has been cited for a total of 253 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 Infinity Park Post-acute And Rehabilitation Center.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 311 nursing homes in Kansas with a total of 14,032 deficiencies resulting in an average of 45.12 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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Honor the resident's right to manage his or her financial affairs.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Assess the resident when there is a significant change in condition
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
N
Survey Date:
2023-02-16
Corrected:

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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Honor the resident's right to manage his or her financial affairs.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Assess the resident when there is a significant change in condition
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
N
Survey Date:
2023-02-16
Corrected:

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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2023-02-16
Corrected:

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-02-16
Corrected:

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:
2022-08-22
Corrected:
2022-10-20

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

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:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
C
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

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:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-11-08

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
C
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-08-22
Corrected:
2022-10-20

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-08-22
Corrected:
2022-10-20

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:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

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:
2022-02-17
Corrected:
2022-03-25

Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

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:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-17
Corrected:
2022-03-25

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-07-27

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-06-17
Corrected:
2021-07-27

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-17
Corrected:
2021-07-27

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:
2021-03-31
Corrected:
2021-04-28

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-31
Corrected:
2021-04-28

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:
2021-03-31
Corrected:
2021-04-28

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-31
Corrected:
2021-04-28

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:
2020-10-28
Corrected:
2020-12-04

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:
2020-10-10
Corrected:
2020-11-17

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:
2020-10-10
Corrected:
2020-11-17

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:
J
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-10
Corrected:
2020-10-22

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-10
Corrected:
2020-11-17

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:
L
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-10
Corrected:
2020-11-17

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-10
Corrected:
2020-10-22

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:
2020-10-08
Corrected:
2020-11-17

Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-08
Corrected:
2020-11-17

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:
2020-10-08
Corrected:
2020-11-17

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:
2020-10-08
Corrected:
2020-11-17

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:
2020-10-08
Corrected:
2020-11-17

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:
G
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-08
Corrected:
2020-11-17

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:
J
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-08
Corrected:
2020-11-17

Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-08
Corrected:
2020-11-17

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
K
From Complaint:
Y
Standard:
N
Survey Date:
2020-10-08
Corrected:
2020-11-17

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2020-08-04
Corrected:
2020-11-17



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