| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 05/28/2019 | Complaint | TD61 | F0641 | E | | ACCURACY OF ASSESSMENTS§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status. | 06/17/2019 |
| 04/04/2019 | Complaint | W91Z | None | None | None | NoneNone | None |
| 02/07/2019 | Standard | 0238 | F0557 | D | | RESPECT, DIGNITY/RIGHT TO HAVE PRSNL PROPERTY§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0688 | D | | INCREASE/PREVENT DECREASE IN ROM/MOBILITY§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and
§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0756 | D | | DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.
§483.45(c)(2) This review must include a review of the resident's medical chart.
§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.
§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0757 | D | | DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
§483.45(d)(1) In excessive dose (including duplicate drug therapy); or
§483.45(d)(2) For excessive duration; or
§483.45(d)(3) Without adequate monitoring; or
§483.45(d)(4) Without adequate indications for its use; or
§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0759 | E | | FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE§483.45(f) Medication Errors.
The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5 percent or greater; | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0761 | E | | LABEL/STORE DRUGS AND BIOLOGICALS§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0808 | D | | THERAPEUTIC DIET PRESCRIBED BY PHYSICIAN§483.60(e) Therapeutic Diets
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.
§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. | 03/09/2019 |
| 02/07/2019 | Standard | 0238 | F0812 | F | | FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY§483.60(i) Food safety requirements.
The facility must -
§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.
§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. | 03/09/2019 |
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