| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 05/09/2022 | Complaint | VFYG | F0656 | D | | DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. | 06/17/2022 |
| 05/09/2022 | Complaint | VFYG | N0054 | D | 3 | FOLLOW PHYSICIAN ORDERSAll physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift.
| 06/17/2022 |
| 12/22/2021 | Complaint | T2ES | F0689 | J | | FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. | 12/27/2021 |
| 12/22/2021 | Complaint | T2ES | N0201 | J | 1 | RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE(l) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.
| 12/27/2021 |
| 08/25/2021 | Monitor | HDFB | None | None | None | NoneNone | None |
| 08/10/2021 | Complaint | 9EJI | F0880 | E | | INFECTION PREVENTION & CONTROL§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary. | 09/09/2021 |
| 01/14/2021 | Standard | PM7Y | F0657 | D | | CARE PLAN TIMING AND REVISION§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. | 02/12/2021 |
| 01/14/2021 | Standard | PM7Y | N0071 | D | 3 | COMPONENTS OF CARE PLAN(1) Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of:
(a) Physician's orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential.
(b) A preliminary nursing evaluation with physician's orders for immediate care, completed upon admission.
(c) A complete, comprehensive, accurate and reproducible assessment of each resident's functional capacity which is standardized in the facility, and is completed within 14 days of the resident's admission to the facility and every twelve months, thereafter. The assessment must be:
1. Reviewed no less than once every 3 months;
2. Reviewed promptly after a significant change, which is a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem, in the resident's physical or mental condition; and,
3. Revised as appropriate to assure the continued accuracy of the assessment.
| 02/12/2021 |
| 01/12/2021 | Fire/Life/Safety | PM7Y | None | None | None | NoneNone | None |
| 11/05/2020 | Complaint | W0DK | None | None | None | NoneNone | None |
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