| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 07/05/2019 | Complaint | KFC2 | None | None | None | NoneNone | None |
| 05/21/2019 | Complaint | 3TP9 | None | None | None | NoneNone | None |
| 05/06/2019 | Complaint | EBB1 | None | None | None | NoneNone | None |
| 02/05/2019 | Complaint | O2VC | None | None | None | NoneNone | None |
| 09/27/2018 | Complaint | N5JD | None | None | None | NoneNone | None |
| 09/27/2018 | Complaint | SQDT | F0867 | D | | QAPI/QAA IMPROVEMENT ACTIVITIES§483.75(g) Quality assessment and assurance.
§483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; | 10/26/2018 |
| 09/27/2018 | Complaint | Z5MN | F0686 | D | | TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. | 10/26/2018 |
| 09/27/2018 | Complaint | Z5MN | F0760 | D | | RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORSThe facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors. | 10/26/2018 |
| 09/27/2018 | Complaint | Z5MN | 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.
| 10/26/2018 |
| 09/06/2018 | Complaint | SQDT | F0842 | D | | RESIDENT RECORDS - IDENTIFIABLE INFORMATION§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. | 10/26/2018 |
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