Decatur, IL

Decatur Rehab & Health Care Ct

1-star overall rating with 1-star inspections with $25,500 in total fines with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

136 South Dipper Lane, Decatur, IL

(217) 428-7767

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1987-10-23

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	32.3%	89.6% 57.3 pts worse	93.4% 61.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.3% · 4Q avg 32.3%
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	3.3% 0.1 pts better	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.2%	50.3% 47.1 pts better	11.4% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · 4Q avg 3.2%
Percentage of long-stay residents who lose too much weight	0.0%	6.5% 6.5 pts better	5.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.9%	18.5% 0.6 pts better	19.6% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.9% · 4Q avg 17.9%
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	16.0%	15.0% 1 pts worse	14.9% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.0% · 4Q avg 16.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.1% 1.1 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	6.4%	21.3% 14.9 pts better	19.8% 13.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · 4Q avg 6.4%
Percentage of long-stay residents with pressure ulcers	6.6%	5.2% 1.4 pts worse	5.1% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · 4Q avg 6.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-25 · Fire 2024-09-25

20 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Cycle 2 Health 2023-08-22 · Fire 2023-08-22

31 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Cycle 3 Health 2022-07-27 · Fire 2022-07-27

43 health deficiencies

Top issue: Quality of Life and Care (12 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-25

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-11-04

F · Potential for more than minimal harm 2024-09-25

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-11-04

F · Potential for more than minimal harm 2024-09-25

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-11-04

F · Potential for more than minimal harm 2024-09-25

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-11-04

F · Potential for more than minimal harm 2024-09-25

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-11-04

F · Potential for more than minimal harm 2024-09-25

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-11-15

F · Potential for more than minimal harm 2024-02-07

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2024-02-16

F · Potential for more than minimal harm 2023-08-22

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2023-08-31

F · Potential for more than minimal harm 2023-08-22

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2023-08-31

F · Potential for more than minimal harm 2023-08-22

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2023-08-31

F · Potential for more than minimal harm 2023-08-22

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-08-31

F · Potential for more than minimal harm 2023-08-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-09-26

F · Potential for more than minimal harm 2023-08-22

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-08-31

F · Potential for more than minimal harm 2022-07-27

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2022-09-01

F · Potential for more than minimal harm 2022-07-27

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2022-09-01

F · Potential for more than minimal harm 2022-07-27

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2022-09-01

F · Potential for more than minimal harm 2022-07-27

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2022-09-01

F · Potential for more than minimal harm 2022-07-27

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2022-09-01

F · Potential for more than minimal harm 2022-07-27

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-09-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-11-13

F623 · Resident Rights Deficiencies

Health

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

Corrected 2024-11-14

E · Potential for more than minimal harm 2024-11-13

F660 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-11-14

G · Actual harm 2024-09-25

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-18

F · Potential for more than minimal harm 2024-09-25

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-25

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-25

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-25

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-10-18

F · Potential for more than minimal harm 2024-09-25

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-25

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-25

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-25

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F644 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F805 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F883 · Infection Control Deficiencies

Health

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

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-25

F919 · Environmental Deficiencies

Health

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

Corrected 2024-10-18

F · Potential for more than minimal harm 2024-09-19

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-10-08

D · Potential for more than minimal harm 2024-08-20

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-20

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-20

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-20

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-05-08

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-05-30

E · Potential for more than minimal harm 2024-05-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-30

E · Potential for more than minimal harm 2024-05-08

F740 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-05-30

G · Actual harm 2024-04-04

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-17

G · Actual harm 2024-04-04

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-17

F · Potential for more than minimal harm 2024-02-10

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-03-01

E · Potential for more than minimal harm 2024-02-10

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-03-01

E · Potential for more than minimal harm 2024-02-10

F918 · Environmental Deficiencies

Health

Provide a bathroom in or located near each resident’s room.

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-10

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-01-26

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-02-22

F · Potential for more than minimal harm 2023-08-22

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2023-09-14

F · Potential for more than minimal harm 2023-08-22

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-09-14

F · Potential for more than minimal harm 2023-08-22

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2023-11-01

E · Potential for more than minimal harm 2023-08-22

F640 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-09-14

E · Potential for more than minimal harm 2023-08-22

F642 · Resident Assessment and Care Planning Deficiencies

Health

Ensure a qualified health professional conducts resident assessments.

Corrected 2023-09-14

E · Potential for more than minimal harm 2023-08-22

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-14

E · Potential for more than minimal harm 2023-08-22

F758 · Pharmacy Service Deficiencies

Health

Corrected 2023-09-14

E · Potential for more than minimal harm 2023-08-22

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2023-09-14

E · Potential for more than minimal harm 2023-08-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-14

E · Potential for more than minimal harm 2023-08-22

F924 · Environmental Deficiencies

Health

Put firmly secured handrails on each side of hallways.

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F636 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-22

F740 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-09-14

C · Minimal harm 2023-08-22

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2023-09-19

F · Potential for more than minimal harm 2023-07-31

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-31

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-31

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-31

F740 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-08-11

D · Potential for more than minimal harm 2023-07-31

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-08-11

F · Potential for more than minimal harm 2023-05-25

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-04-05

F690 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-21

F · Potential for more than minimal harm 2023-03-08

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-08

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-24

C · Minimal harm 2023-03-08

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-03-24

G · Actual harm 2022-07-27

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-23

G · Actual harm 2022-07-27

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-08

F · Potential for more than minimal harm 2022-07-27

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-09-23

F · Potential for more than minimal harm 2022-07-27

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-09-23

F · Potential for more than minimal harm 2022-07-27

F868 · Administration Deficiencies

Health

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

Corrected 2022-09-08

F · Potential for more than minimal harm 2022-07-27

F882 · Infection Control Deficiencies

Health

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

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27

F552 · Resident Rights Deficiencies

Health

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

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27

F580 · Resident Rights Deficiencies

Health

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

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-09-08

E · Potential for more than minimal harm 2022-07-27