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🔎 Manorcare Health Services-hemet

Inspection Results


Inspection Overview

Manorcare Health Services-hemet has been cited for a total of 143 deficiencies since we began saving each survey.

In California, the average facility has **64.18 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: G

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

Survey Date: 2025-04-10
Correction Date: 2025-04-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-04-10
Correction Date: 2025-04-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2025-01-17
Correction Date: 2025-02-07
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: 2025-01-17
Correction Date: 2025-02-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2025-01-17
Correction Date: 2025-02-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2025-01-17
Correction Date: 2025-02-07
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: 2025-01-17
Correction Date: 2025-02-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-01-17
Correction Date: 2025-02-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-01-17
Correction Date: 2025-02-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-01-17
Correction Date: 2025-02-07
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: 2025-01-17
Correction Date: 2025-02-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2025-01-17
Correction Date: 2025-02-07
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: 2025-01-17
Correction Date: 2025-02-07
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2025-01-17
Correction Date: 2025-02-07
Category: Infection Control 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: 2024-11-08
Correction Date: 2024-11-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-11-08
Correction Date: 2024-11-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-11-08
Correction Date: 2024-11-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-11-08
Correction Date: 2024-11-15
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-11-05
Correction Date: 2024-11-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2024-11-05
Correction Date: 2024-11-22
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-11-05
Correction Date: 2024-11-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-11-05
Correction Date: 2024-11-22
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-10-29
Correction Date: 2024-11-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-08-23
Correction Date: 2024-09-13
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: 2024-08-23
Correction Date: 2024-09-13
Category: Resident Rights 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: 2024-08-23
Correction Date: 2024-09-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-08-23
Correction Date: 2024-09-13
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: 2024-08-23
Correction Date: 2024-09-13
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: 2024-08-23
Correction Date: 2024-09-13
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Post nurse staffing information every day.

Survey Date: 2024-06-26
Correction Date: 2024-07-15
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-19
Correction Date: 2024-07-10
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: 2024-06-19
Correction Date: 2024-07-10
Category: Resident Rights 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: 2024-06-19
Correction Date: 2024-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-05-21
Correction Date: 2024-06-12
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: 2024-05-21
Correction Date: 2024-06-12
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: 2024-05-09
Correction Date: 2024-05-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-05-07
Correction Date: 2024-05-29
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: 2024-04-10
Correction Date: 2024-04-20
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: 2024-04-10
Correction Date: 2024-04-20
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: 2024-03-21
Correction Date: 2024-04-03
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: 2024-03-21
Correction Date: 2024-04-03
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: 2024-03-21
Correction Date: 2024-04-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-03-21
Correction Date: 2024-04-03
Category: Quality of Life and Care 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: 2023-12-27
Correction Date: 2024-01-26
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2023-12-13
Correction Date: 2024-01-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-10-05
Correction Date: 2023-11-04
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-08-21
Correction Date: 2023-09-15
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: 2023-04-24
Correction Date: 2023-05-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-04-24
Correction Date: 2023-05-24
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: 2023-04-24
Correction Date: 2023-05-24
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: 2023-04-24
Correction Date: 2023-06-26
Category: Resident Rights Deficiencies
From Complaint: N

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: 2023-04-24
Correction Date: 2023-05-24
Category: Resident Rights 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: 2023-04-24
Correction Date: 2023-05-24
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: 2023-04-24
Correction Date: 2023-05-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

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

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: H

Provide appropriate foot care.

Survey Date: 2023-04-24
Correction Date: 2023-05-24
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: 2023-04-24
Correction Date: 2023-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Nursing and Physician Services 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: 2023-04-24
Correction Date: 2023-05-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-04-24
Correction Date: 2023-06-26
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: 2023-04-24
Correction Date: 2023-05-24
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: 2023-04-24
Correction Date: 2023-05-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-04-24
Correction Date: 2023-06-26
Category: Administration 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: 2023-04-24
Correction Date: 2023-05-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2023-04-24
Correction Date: 2023-05-24
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: 2023-04-24
Correction Date: 2023-05-24
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-04-24
Correction Date: 2023-05-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-07-12
Correction Date: 2022-08-12
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-01-13
Correction Date: 2022-01-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Survey Date: 2022-01-12
Correction Date: 2022-03-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-05-13
Correction Date: 2021-06-07
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: 2021-03-16
Correction Date: 2021-04-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-03-10
Correction Date: 2021-04-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-03-10
Correction Date: 2021-04-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: C

Report COVID19 data to residents and families.

Survey Date: 2021-03-10
Correction Date: 2021-04-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Perform COVID19 testing on residents and staff.

Survey Date: 2021-03-10
Correction Date: 2021-04-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-09
Correction Date: 2021-03-02
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-11-04
Correction Date: 2020-11-25
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: 2020-11-03
Correction Date: 2020-11-30
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-10-20
Correction Date: 2020-11-09
Category: Quality of Life and Care 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: 2020-10-06
Correction Date: 2020-10-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-10-06
Correction Date: 2020-10-19
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: 2020-09-10
Correction Date: 2020-09-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-09-09
Correction Date: 2020-10-08
Category: Infection Control 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: 2020-08-21
Correction Date: 2020-09-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

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: 2020-02-27
Correction Date: 2020-09-14
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: 2020-02-27
Correction Date: 2020-09-14
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: 2020-02-27
Correction Date: 2020-09-14
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: 2020-02-27
Correction Date: 2020-09-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-02-27
Correction Date: 2020-09-14
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: 2020-02-27
Correction Date: 2020-09-14
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: 2020-02-27
Correction Date: 2020-09-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-02-27
Correction Date: 2020-09-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-02-27
Correction Date: 2020-09-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-02-27
Correction Date: 2020-09-14
Category: Administration 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: 2020-02-27
Correction Date: 2020-09-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2020-02-27
Correction Date: 2020-09-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-02-27
Correction Date: 2020-09-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-03-07
Correction Date: 2019-05-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

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

Scope/Severity: D

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

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

Scope/Severity: D

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

Survey Date: 2019-03-07
Correction Date: 2019-05-01
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: 2019-03-07
Correction Date: 2019-05-01
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: 2019-03-07
Correction Date: 2019-05-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-03-07
Correction Date: 2019-05-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-03-07
Correction Date: 2019-05-01
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: 2019-03-07
Correction Date: 2019-05-01
Category: Pharmacy Service 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: 2019-03-07
Correction Date: 2019-05-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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: 2019-03-07
Correction Date: 2019-05-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-03-07
Correction Date: 2019-05-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-03-07
Correction Date: 2019-05-01
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2018-03-16
Correction Date: 2018-04-23
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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: 2018-03-16
Correction Date: 2018-04-23
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

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: 2018-03-16
Correction Date: 2018-04-23
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2018-03-16
Correction Date: 2018-04-23
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2018-03-16
Correction Date: 2018-04-23
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.**