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🔎 Silver Springs Health Care Center

Inspection Results


Inspection Overview

Silver Springs Health Care Center has been cited for a total of 145 deficiencies since we began saving each survey.

In Wisconsin, the average facility has **36.64 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

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

Survey Date: 2025-01-29
Correction Date: 2025-02-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-01-29
Correction Date: 2025-02-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

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: 2025-01-29
Correction Date: 2025-02-27
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: 2025-01-29
Correction Date: 2025-02-27
Category: Resident Rights Deficiencies
From Complaint: Y

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: 2025-01-29
Correction Date: 2025-02-27
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2025-01-29
Correction Date: 2025-02-27
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-10-30
Correction Date: 2025-02-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-10-30
Correction Date: 2024-12-02
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2024-10-30
Correction Date: 2024-12-02
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-10-30
Correction Date: 2024-12-02
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-07-24
Correction Date: 2024-08-15
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Resident Rights 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: 2024-06-20
Correction Date: 2024-07-25
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Resident Assessment and Care Planning 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: 2024-06-20
Correction Date: 2024-07-25
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2024-06-20
Correction Date: 2024-07-25
Category: Environmental 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: 2024-06-20
Correction Date: 2024-07-25
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-05-30
Correction Date: 2024-06-16
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-05-30
Correction Date: 2024-06-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-05-30
Correction Date: 2024-06-16
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-10-10
Correction Date: 2023-11-07
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: 2023-10-10
Correction Date: 2023-11-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-10-10
Correction Date: 2023-11-07
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: 2023-10-10
Correction Date: 2023-11-07
Category: Quality of Life and Care 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: 2023-10-10
Correction Date: 2023-11-07
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-10-10
Correction Date: 2023-11-07
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

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: 2023-10-10
Correction Date: 2023-11-07
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2023-10-10
Correction Date: 2023-11-07
Category: Environmental 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: 2023-07-24
Correction Date: 2023-08-22
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: 2023-07-24
Correction Date: 2023-08-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2023-07-24
Correction Date: 2023-08-22
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2023-07-24
Correction Date: 2023-08-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

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: 2023-07-24
Correction Date: 2023-08-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2023-07-24
Correction Date: 2023-08-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2023-07-24
Correction Date: 2023-08-22
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: 2023-07-24
Correction Date: 2023-08-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2023-07-24
Correction Date: 2023-08-22
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: 2023-07-24
Correction Date: 2023-08-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

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: 2023-07-24
Correction Date: 2023-08-22
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2023-07-24
Correction Date: 2023-08-22
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-05-17
Correction Date: 2023-08-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-05-17
Correction Date: 2023-08-22
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: 2023-05-17
Correction Date: 2023-08-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Resident Rights Deficiencies
From Complaint: Y

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: 2023-03-21
Correction Date: 2023-05-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
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: 2023-03-21
Correction Date: 2023-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: L

Provide and implement an infection prevention and control program.

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: L

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

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Infection Control 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: 2023-03-21
Correction Date: 2023-05-17
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: 2023-03-21
Correction Date: 2023-05-17
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: 2023-03-21
Correction Date: 2023-05-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-06-13
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: 2023-03-21
Correction Date: 2023-05-17
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: 2023-03-21
Correction Date: 2023-05-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-03-21
Correction Date: 2023-06-13
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: 2023-03-21
Correction Date: 2023-05-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2023-03-21
Correction Date: 2023-06-13
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: 2023-03-21
Correction Date: 2023-05-17
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: 2023-03-21
Correction Date: 2023-05-17
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: 2023-03-21
Correction Date: 2023-05-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: C

Dispose of garbage and refuse properly.

Survey Date: 2023-03-21
Correction Date: 2023-05-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2023-03-21
Correction Date: 2023-08-22
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Freedom from Abuse, Neglect, and Exploitation 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: 2022-08-23
Correction Date: 2022-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

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: 2022-08-23
Correction Date: 2022-09-21
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-08-23
Correction Date: 2022-09-21
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-08
Correction Date: 2022-03-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-08
Correction Date: 2022-03-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-08
Correction Date: 2022-03-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-02-08
Correction Date: 2022-03-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-02-08
Correction Date: 2022-03-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-02-08
Correction Date: 2022-03-07
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-01-06
Correction Date: 2022-02-04
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Give the resident's representative the ability to exercise the resident's rights.

Survey Date: 2021-12-01
Correction Date: 2022-01-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-12-01
Correction Date: 2022-01-05
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: 2021-12-01
Correction Date: 2022-01-05
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: 2021-12-01
Correction Date: 2022-01-05
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: 2021-12-01
Correction Date: 2022-01-05
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-12-01
Correction Date: 2022-01-05
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2021-12-01
Correction Date: 2022-01-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-12-01
Correction Date: 2022-01-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-12-01
Correction Date: 2022-01-05
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: 2021-12-01
Correction Date: 2022-01-05
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: 2021-12-01
Correction Date: 2022-01-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-12-01
Correction Date: 2022-01-05
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: 2021-12-01
Correction Date: 2022-01-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: C

Dispose of garbage and refuse properly.

Survey Date: 2021-12-01
Correction Date: 2022-01-05
Category: Nutrition and Dietary 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: 2021-12-01
Correction Date: 2022-01-05
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-12-01
Correction Date: 2022-01-05
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-10-19
Correction Date: 2021-11-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-10-19
Correction Date: 2021-11-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-06-09
Correction Date: 2021-07-05
Category: Quality of Life and Care 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: 2020-12-15
Correction Date: 2021-01-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2020-12-15
Correction Date: 2021-01-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

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

Survey Date: 2020-12-15
Correction Date: 2021-01-08
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: 2020-12-15
Correction Date: 2021-01-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-12-15
Correction Date: 2021-01-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-15
Correction Date: 2021-01-08
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2020-08-18
Correction Date: 2020-10-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

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: 2020-08-18
Correction Date: 2020-10-01
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2020-08-18
Correction Date: 2020-10-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2020-08-18
Correction Date: 2020-10-01
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

Report COVID19 data to residents and families.

Survey Date: 2020-08-18
Correction Date: 2020-10-01
Category: Infection Control 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: 2020-01-15
Correction Date: 2020-02-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-01-15
Correction Date: 2020-02-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-01-15
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-01-15
Correction Date: 2020-02-15
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: 2020-01-15
Correction Date: 2020-02-15
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: 2020-01-15
Correction Date: 2020-02-15
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: 2020-01-15
Correction Date: 2020-02-15
Category: Nutrition and Dietary 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: 2019-03-19
Correction Date: 2019-04-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2019-03-19
Correction Date: 2019-04-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-03-19
Correction Date: 2019-04-18
Category: Resident Rights 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: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-03-19
Correction Date: 2019-04-18
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
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: 2019-03-19
Correction Date: 2019-04-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-03-19
Correction Date: 2019-04-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.

Survey Date: 2019-03-19
Correction Date: 2019-04-18
Category: Environmental 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.**