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🔎 Dunbar Center

Inspection Results


Inspection Overview

Dunbar Center has been cited for a total of 143 deficiencies since we began saving each survey.

In West Virginia, the average facility has **60.65 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

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

Survey Date: 2023-07-06
Correction Date: 2023-08-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2023-07-06
Correction Date: 2023-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
Category: Infection Control 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: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-02-15
Correction Date: 2023-03-14
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: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2023-02-15
Correction Date: 2023-03-14
Category: Infection Control 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: 2023-02-15
Correction Date: 2023-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-03
Correction Date: 2022-08-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-03
Correction Date: 2022-06-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-08-03
Correction Date: 2022-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-03
Correction Date: 2022-08-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-03
Correction Date: 2022-06-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-08-03
Correction Date: 2022-08-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Post nurse staffing information every day.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Put firmly secured handrails on each side of hallways.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
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: 2021-11-03
Correction Date: 2021-11-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Post nurse staffing information every day.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Put firmly secured handrails on each side of hallways.

Survey Date: 2021-11-03
Correction Date: 2021-11-24
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-11-11
Correction Date: 2020-11-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-13
Correction Date: 2020-11-25
Category: Infection Control Deficiencies
From Complaint: N

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: 2020-09-25
Correction Date: 2020-11-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

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: 2020-09-25
Correction Date: 2020-11-11
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2020-08-20
Correction Date: 2020-09-29
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-07-02
Correction Date: 2019-09-18
Category: Resident Rights 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: 2019-07-02
Correction Date: 2019-10-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
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: 2019-07-02
Correction Date: 2019-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-10-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-09-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

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: 2019-07-02
Correction Date: 2019-08-21
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-10-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-10-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-07-02
Correction Date: 2019-09-18
Category: Resident Rights 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: 2019-07-02
Correction Date: 2019-10-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
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: 2019-07-02
Correction Date: 2019-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-10-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-09-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

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: 2019-07-02
Correction Date: 2019-08-21
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-10-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-08-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-08-21
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: 2019-07-02
Correction Date: 2019-10-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-07-02
Correction Date: 2019-10-10
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**