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🔎 Promedica Skilled Nursing And Rehab Marietta

Inspection Results


Inspection Overview

Promedica Skilled Nursing And Rehab Marietta has been cited for a total of 157 deficiencies since we began saving each survey.

In Ohio, the average facility has **39.51 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: E

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Survey Date: 2025-05-15
Correction Date: 2025-06-25
Category: Resident Rights 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: 2025-03-14
Correction Date: 2025-05-15
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: 2025-03-14
Correction Date: 2025-05-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2025-03-14
Correction Date: 2025-05-15
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: 2025-03-14
Correction Date: 2025-05-15
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: 2025-03-14
Correction Date: 2025-05-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2025-03-14
Correction Date: 2025-06-25
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: 2025-03-14
Correction Date: 2025-04-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-14
Correction Date: 2025-06-25
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: 2025-03-14
Correction Date: 2025-05-15
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: 2025-03-14
Correction Date: 2025-05-15
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: 2025-03-14
Correction Date: 2025-06-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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: 2025-03-14
Correction Date: 2025-05-15
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2025-03-14
Correction Date: 2025-06-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Nutrition and Dietary 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: 2025-03-14
Correction Date: 2025-06-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Nutrition and Dietary 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: 2025-03-14
Correction Date: 2025-06-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Implement a program that monitors antibiotic use.

Survey Date: 2025-03-14
Correction Date: 2025-06-25
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: 2025-03-14
Correction Date: 2025-05-15
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

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: 2025-03-14
Correction Date: 2025-06-25
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2025-03-14
Correction Date: 2025-05-15
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-12-11
Correction Date: 2025-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-12-11
Correction Date: 2025-01-15
Category: Administration 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: 2024-11-26
Correction Date: 2025-01-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-11-26
Correction Date: 2025-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-10-11
Correction Date: 2024-11-26
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: 2024-10-11
Correction Date: 2025-01-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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: 2024-10-11
Correction Date: 2024-11-26
Category: Resident Rights 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: 2024-10-11
Correction Date: 2024-11-26
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: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2024-10-11
Correction Date: 2024-11-26
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: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-10-11
Correction Date: 2024-11-26
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: 2024-10-11
Correction Date: 2024-11-26
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: 2024-10-11
Correction Date: 2025-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

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

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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: 2024-10-11
Correction Date: 2024-11-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2024-10-11
Correction Date: 2025-02-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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: 2024-10-11
Correction Date: 2024-11-26
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-10-11
Correction Date: 2024-11-26
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2024-06-10
Correction Date: 2024-07-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2024-06-10
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2024-06-10
Correction Date: 2024-07-11
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-10
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

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: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

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: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning 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: 2024-04-18
Correction Date: 2024-07-11
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: 2024-04-18
Correction Date: 2024-07-11
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: 2024-04-18
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
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: 2024-04-18
Correction Date: 2024-07-11
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: 2024-04-18
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: L

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: F

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: F

Have a plan that describes the process for conducting QAPI and QAA activities.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Implement a program that monitors antibiotic use.

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-04-18
Correction Date: 2024-07-11
Category: Infection Control 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: 2024-04-18
Correction Date: 2024-07-11
Category: Environmental 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: 2023-02-03
Correction Date: 2023-02-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-02-03
Correction Date: 2023-02-22
Category: Resident Rights 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: 2023-02-03
Correction Date: 2023-02-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-02-03
Correction Date: 2023-02-22
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: 2023-02-03
Correction Date: 2023-02-22
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: 2023-02-03
Correction Date: 2023-02-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2023-02-03
Correction Date: 2023-02-22
Category: Quality of Life and Care 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: 2023-02-03
Correction Date: 2023-02-22
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: 2023-02-03
Correction Date: 2023-02-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2023-02-03
Correction Date: 2023-02-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-11-30
Correction Date: 2022-12-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-11-30
Correction Date: 2022-12-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2022-11-30
Correction Date: 2022-12-21
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-04-28
Correction Date: 2022-05-18
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: 2022-03-31
Correction Date: 2022-05-18
Category: Quality of Life and Care 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: 2022-01-12
Correction Date: 2022-01-28
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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: 2022-01-12
Correction Date: 2022-01-28
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2022-01-12
Correction Date: 2022-01-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-01-12
Correction Date: 2022-01-28
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-10-08
Correction Date: 2021-11-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-09-24
Correction Date: 2021-11-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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: 2021-04-30
Correction Date: 2021-07-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Quality of Life and Care 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: 2021-04-30
Correction Date: 2021-07-07
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: 2021-04-30
Correction Date: 2021-07-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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: 2021-04-30
Correction Date: 2021-07-23
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: 2021-04-30
Correction Date: 2021-07-07
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: 2021-04-30
Correction Date: 2021-07-07
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Implement a program that monitors antibiotic use.

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Infection Control 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: 2021-04-30
Correction Date: 2021-07-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2021-04-30
Correction Date: 2021-07-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-20
Correction Date: 2020-11-22
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Keep residents' personal and medical records private and confidential.

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Resident Rights 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: 2019-01-31
Correction Date: 2019-04-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Resident Assessment and Care Planning 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: 2019-01-31
Correction Date: 2019-04-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Honor each resident's preferences, choices, values and beliefs.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
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: 2019-01-31
Correction Date: 2019-04-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2019-01-31
Correction Date: 2019-05-07
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: 2019-01-31
Correction Date: 2019-04-03
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: 2019-01-31
Correction Date: 2019-05-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-31
Correction Date: 2019-04-03
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: 2019-01-31
Correction Date: 2019-04-03
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-01-31
Correction Date: 2019-05-07
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: 2019-01-31
Correction Date: 2019-05-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-01-31
Correction Date: 2019-05-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Administration 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: 2019-01-31
Correction Date: 2019-05-07
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Implement a program that monitors antibiotic use.

Survey Date: 2019-01-31
Correction Date: 2019-04-03
Category: Infection Control Deficiencies
From Complaint: N


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