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🔎 Providence Marianwood

Inspection Results


Inspection Overview

Providence Marianwood has been cited for a total of 150 deficiencies since we began saving each survey.

In Washington, the average facility has **97.59 deficiencies** per survey cycle. 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: 2023-04-25
Correction Date: 2023-06-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2023-04-25
Correction Date: 2023-06-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2023-04-25
Correction Date: 2023-06-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
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: 2023-04-25
Correction Date: 2023-06-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2023-04-25
Correction Date: 2023-06-07
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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate foot care.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care 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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service 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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service 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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate foot care.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care 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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service 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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service 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: 2021-09-16
Correction Date: 2021-10-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
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: 2021-09-16
Correction Date: 2021-10-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-09-16
Correction Date: 2021-10-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-11
Correction Date: 2021-01-06
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2020-12-03
Correction Date: 2021-01-06
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: 2020-12-03
Correction Date: 2021-01-06
Category: Quality of Life and Care 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: 2020-12-03
Correction Date: 2021-01-06
Category: Quality of Life and Care 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: 2020-11-16
Correction Date: 2020-12-15
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: 2020-11-16
Correction Date: 2020-12-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2020-11-16
Correction Date: 2020-12-15
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2020-11-16
Correction Date: 2020-12-15
Category: Quality of Life and Care 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: 2020-09-28
Correction Date: 2020-12-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-09-02
Correction Date: 2020-09-23
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2020-08-19
Correction Date: 2020-09-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-07-28
Correction Date: 2020-08-10
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Quality of Life and Care 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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Pharmacy Service 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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Infection Control 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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Quality of Life and Care 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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Pharmacy Service 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: 2019-01-16
Correction Date: 2019-02-20
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: 2019-01-16
Correction Date: 2019-02-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-01-16
Correction Date: 2019-02-20
Category: Infection Control Deficiencies
From Complaint: N


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