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🔎 Murrysville Rehabilitation And Wellness Center

Inspection Results


Inspection Overview

Murrysville Rehabilitation And Wellness Center has been cited for a total of 130 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 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

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Resident Rights Deficiencies
From Complaint: N

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: 2025-03-28
Correction Date: 2025-05-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
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: 2025-03-28
Correction Date: 2025-05-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
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: 2025-03-28
Correction Date: 2025-05-20
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: 2025-03-28
Correction Date: 2025-05-20
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: 2025-03-28
Correction Date: 2025-05-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
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: 2025-03-28
Correction Date: 2025-05-20
Category: Nursing and Physician Services 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: 2025-03-28
Correction Date: 2025-05-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-03-28
Correction Date: 2025-05-20
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: 2025-03-28
Correction Date: 2025-05-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Keep all essential equipment working safely.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Have enough backup water supply for essential areas of the nursing home.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Survey Date: 2025-03-28
Correction Date: 2025-05-20
Category: Administration 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: 2025-03-28
Correction Date: 2025-05-20
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-01-17
Correction Date: 2025-02-19
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: 2025-01-17
Correction Date: 2025-02-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

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: 2025-01-17
Correction Date: 2025-02-19
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Employ staff that are licensed, certified, or registered in accordance with state laws.

Survey Date: 2025-01-17
Correction Date: 2025-02-19
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-01-17
Correction Date: 2025-02-19
Category: Administration 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: 2024-12-10
Correction Date: 2025-01-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2024-10-29
Correction Date: 2024-11-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-10-29
Correction Date: 2024-11-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-09-25
Correction Date: 2024-10-08
Category: Administration Deficiencies
From Complaint: Y

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: 2024-09-13
Correction Date: 2024-10-08
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: 2024-09-13
Correction Date: 2024-10-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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: 2024-08-20
Correction Date: 2024-09-09
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: 2024-08-20
Correction Date: 2024-09-09
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-04-05
Correction Date: 2024-04-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

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: 2024-04-05
Correction Date: 2024-04-29
Category: Resident Rights 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: 2024-04-05
Correction Date: 2024-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-04-05
Correction Date: 2024-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-04-05
Correction Date: 2024-04-29
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-04-05
Correction Date: 2024-04-29
Category: Administration 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: 2024-04-05
Correction Date: 2024-04-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-04-05
Correction Date: 2024-04-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2024-04-05
Correction Date: 2024-04-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2024-04-05
Correction Date: 2024-04-29
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: 2024-04-05
Correction Date: 2024-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2024-01-24
Correction Date: 2024-02-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2024-01-24
Correction Date: 2024-02-21
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: 2024-01-24
Correction Date: 2024-02-21
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: 2024-01-24
Correction Date: 2024-02-21
Category: Quality of Life and Care 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: 2024-01-24
Correction Date: 2024-02-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2024-01-24
Correction Date: 2024-02-21
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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: 2023-12-27
Correction Date: 2024-01-25
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-10-05
Correction Date: 2023-10-19
Category: Quality of Life and Care 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: 2023-09-22
Correction Date: 2023-10-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-09-22
Correction Date: 2023-10-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2023-05-09
Correction Date: 2023-05-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-04-19
Correction Date: 2023-05-23
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: 2023-04-19
Correction Date: 2023-05-23
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: 2023-04-19
Correction Date: 2023-05-23
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: 2023-04-19
Correction Date: 2023-05-23
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2023-04-19
Correction Date: 2023-05-23
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-04-19
Correction Date: 2023-05-23
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-04-19
Correction Date: 2023-05-23
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Survey Date: 2023-04-19
Correction Date: 2023-05-23
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-04-19
Correction Date: 2023-05-23
Category: Pharmacy Service 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: 2022-12-19
Correction Date: 2023-01-10
Category: Resident Assessment and Care Planning 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: 2022-11-15
Correction Date: 2022-11-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

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: 2022-09-21
Correction Date: 2022-10-18
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2022-09-21
Correction Date: 2022-11-21
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-26
Correction Date: 2022-09-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Employ staff that are licensed, certified, or registered in accordance with state laws.

Survey Date: 2022-08-26
Correction Date: 2022-09-20
Category: Administration 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: 2022-05-09
Correction Date: 2022-06-09
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
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: 2022-05-09
Correction Date: 2022-06-09
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Ensure staff are vaccinated for COVID-19

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Have enough outside ventilation via a window or mechanical ventilation, or both.

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-05-09
Correction Date: 2022-06-09
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-03-25
Correction Date: 2022-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2022-02-07
Correction Date: 2022-02-18
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Survey Date: 2021-11-18
Correction Date: 2021-12-17
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: 2021-11-18
Correction Date: 2021-12-17
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: 2021-11-18
Correction Date: 2021-12-17
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: 2021-01-11
Correction Date: 2021-02-24
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: 2021-01-11
Correction Date: 2021-02-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-01-11
Correction Date: 2021-02-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-01-11
Correction Date: 2021-02-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Post nurse staffing information every day.

Survey Date: 2021-01-11
Correction Date: 2021-02-24
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: 2021-01-11
Correction Date: 2021-02-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2021-01-11
Correction Date: 2021-02-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2021-01-11
Correction Date: 2021-02-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2021-01-11
Correction Date: 2021-02-24
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: 2021-01-11
Correction Date: 2021-02-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-11-17
Correction Date: 2020-12-04
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-11-17
Correction Date: 2020-12-04
Category: Infection Control Deficiencies
From Complaint: Y

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: 2020-10-14
Correction Date: 2020-11-14
Category: Resident Assessment and Care Planning 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: 2020-10-14
Correction Date: 2020-11-14
Category: Nursing and Physician Services 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: 2019-04-19
Correction Date: 2019-05-08
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-04-19
Correction Date: 2019-05-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-04-19
Correction Date: 2019-05-08
Category: Resident Assessment and Care Planning 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: 2019-04-19
Correction Date: 2019-05-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-04-19
Correction Date: 2019-05-08
Category: Infection Control Deficiencies
From Complaint: N


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