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🔎 Hillside Rehab And Healthcare Center

Inspection Results


Inspection Overview

Hillside Rehab And Healthcare Center has been cited for a total of 177 deficiencies since we began saving each survey.

In Missouri, the average facility has **43.77 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 appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-03-20
Correction Date: 2025-03-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2025-03-20
Correction Date: 2025-03-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2025-03-20
Correction Date: 2025-03-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-02-06
Correction Date: 2025-03-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2025-02-06
Correction Date: 2025-03-26
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: 2025-02-06
Correction Date: 2025-03-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-02-06
Correction Date: 2025-03-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2025-02-06
Correction Date: 2025-03-26
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: 2024-11-05
Correction Date: 2024-11-26
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-11-05
Correction Date: 2024-11-26
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Put firmly secured handrails on each side of hallways.

Survey Date: 2024-11-05
Correction Date: 2024-11-26
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
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: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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: 2024-07-16
Correction Date: 2024-09-05
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: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: J

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: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

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: 2024-07-16
Correction Date: 2024-08-26
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care 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: 2024-07-16
Correction Date: 2024-09-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Implement a program that monitors antibiotic use.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
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: 2024-07-16
Correction Date: 2024-08-26
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Resident Rights 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: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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: 2024-07-16
Correction Date: 2024-08-26
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that residents are free from significant medication errors.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-07-16
Correction Date: 2024-09-04
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Survey Date: 2024-07-16
Correction Date: 2024-08-26
Category: Environmental 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: 2024-01-19
Correction Date: 2024-02-07
Category: Resident Rights 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: 2023-11-08
Correction Date: 2023-11-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-11-08
Correction Date: 2023-11-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-11-08
Correction Date: 2023-11-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Survey Date: 2023-11-08
Correction Date: 2023-11-20
Category: Nursing and Physician Services 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: 2023-09-14
Correction Date: 2023-09-14
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2023-09-14
Correction Date: 2023-10-17
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-09-14
Correction Date: 2023-11-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-09-14
Correction Date: 2023-11-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-09-14
Correction Date: 2023-10-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Survey Date: 2023-09-14
Correction Date: 2023-11-20
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2023-09-14
Correction Date: 2023-10-17
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: L

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.

Survey Date: 2023-08-01
Correction Date: 2023-08-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-07-14
Correction Date: 2023-08-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2023-07-14
Correction Date: 2023-08-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-07-14
Correction Date: 2023-08-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2023-07-14
Correction Date: 2023-08-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-03-30
Correction Date: 2023-04-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2023-03-30
Correction Date: 2023-04-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-30
Correction Date: 2023-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-30
Correction Date: 2023-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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: 2023-03-30
Correction Date: 2023-04-18
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: 2023-02-23
Correction Date: 2023-03-23
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2023-02-23
Correction Date: 2023-03-23
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-01-18
Correction Date: 2023-04-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2023-01-18
Correction Date: 2023-04-18
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: 2023-01-18
Correction Date: 2023-03-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-01-18
Correction Date: 2023-01-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-01-18
Correction Date: 2023-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-01-18
Correction Date: 2023-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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: 2023-01-18
Correction Date: 2023-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2022-10-28
Correction Date: 2022-11-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Hire a qualified full-time social worker in a facility with more than 120 beds.

Survey Date: 2022-10-28
Correction Date: 2022-11-29
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2022-10-28
Correction Date: 2022-11-29
Category: Environmental 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: 2022-09-15
Correction Date: 2022-10-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-09-15
Correction Date: 2022-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-09-15
Correction Date: 2022-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-09-15
Correction Date: 2022-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-08-15
Correction Date: 2022-08-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2022-08-15
Correction Date: 2022-09-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-07-13
Correction Date: 2022-08-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-06-22
Correction Date: 2022-09-15
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: 2022-06-22
Correction Date: 2022-10-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-06-22
Correction Date: 2022-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-06-22
Correction Date: 2022-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-06-22
Correction Date: 2022-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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: 2022-06-22
Correction Date: 2022-08-03
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: C

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.

Survey Date: 2022-05-02
Correction Date: 2022-05-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

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: 2022-05-02
Correction Date: 2022-05-09
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: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Assure the security of all personal funds of residents deposited with the facility.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

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

Survey Date: 2022-01-25
Correction Date: 2022-03-10
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: 2022-01-25
Correction Date: 2022-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-01-25
Correction Date: 2022-03-10
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: 2022-01-25
Correction Date: 2022-03-10
Category: Quality of Life and Care 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: 2022-01-25
Correction Date: 2022-03-10
Category: Pharmacy Service 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: 2022-01-25
Correction Date: 2022-03-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
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: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-01-25
Correction Date: 2022-03-10
Category: Nutrition and Dietary 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: 2021-02-03
Correction Date: 2021-03-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-02-03
Correction Date: 2021-03-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2021-02-03
Correction Date: 2021-03-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-06-26
Correction Date: 2020-08-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2019-12-24
Correction Date: 2020-01-28
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: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: L

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-12-24
Correction Date: 2020-01-28
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: 2019-12-24
Correction Date: 2020-01-28
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: 2019-12-24
Correction Date: 2020-01-28
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: 2019-12-24
Correction Date: 2020-01-28
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: 2019-12-24
Correction Date: 2020-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Observe each nurse aide's job performance and give regular training.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
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: 2019-12-24
Correction Date: 2020-01-28
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Pharmacy Service 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: 2019-12-24
Correction Date: 2020-01-28
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Administration 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: 2019-12-24
Correction Date: 2020-02-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2019-12-24
Correction Date: 2020-01-28
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

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: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-01-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-01-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-01-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-02-01
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: 2018-11-13
Correction Date: 2019-01-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Pharmacy Service 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: 2018-11-13
Correction Date: 2019-01-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
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: 2018-11-13
Correction Date: 2019-01-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2018-11-13
Correction Date: 2019-01-11
Category: Infection Control 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.**