Spring Hill Rehabilitation and Nursing Center

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jul 14, 2026)

FElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Potential for more than minimal harm · Administration Deficiencies · Tag F0851 · Deficient, Provider has date of correction (Jul 14, 2026)

EEducate 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.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0887 · Deficient, Provider has date of correction (Jul 14, 2026)

EKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Deficient, Provider has date of correction (Jul 14, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (Jul 14, 2026)

DHonor the resident's right to manage his or her financial affairs.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0567 · Deficient, Provider has date of correction (Jul 14, 2026)

DProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0568 · Deficient, Provider has date of correction (Jul 14, 2026)

DNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0569 · Deficient, Provider has date of correction (Jul 14, 2026)

DAssure the security of all personal funds of residents deposited with the facility.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0570 · Deficient, Provider has date of correction (Jul 14, 2026)

DGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0582 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Jul 14, 2026)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide care or services that was trauma informed and/or culturally competent.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0699 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0730 · Complaint inspection · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0744 · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide medically-related social services to help each resident achieve the highest possible quality of life.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0745 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Jul 14, 2026)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (Jul 14, 2026)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Jul 14, 2026)

DEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (Jul 14, 2026)

DEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0806 · Deficient, Provider has date of correction (Jul 14, 2026)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Administration Deficiencies · Tag F0868 · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Environmental Deficiencies · Tag F0919 · Deficient, Provider has date of correction (Jul 14, 2026)

DPut firmly secured handrails on each side of hallways.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0924 · Deficient, Provider has date of correction (Jul 14, 2026)

DDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Potential for more than minimal harm · Administration Deficiencies · Tag F0941 · Deficient, Provider has date of correction (Jul 14, 2026)

DGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 · Deficient, Provider has date of correction (Jul 14, 2026)

DConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Potential for more than minimal harm · Administration Deficiencies · Tag F0944 · Deficient, Provider has date of correction (Jul 14, 2026)

DInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0945 · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide training in compliance and ethics.

Potential for more than minimal harm · Administration Deficiencies · Tag F0946 · Deficient, Provider has date of correction (Jul 14, 2026)

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

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide behavior health training consistent with the requirements and as determined by a facility assessment.

Potential for more than minimal harm · Administration Deficiencies · Tag F0949 · Deficient, Provider has date of correction (Jul 14, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

EProtect each resident from the wrongful use of the resident's belongings or money.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

ERespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

EAdminister the facility in a manner that enables it to use its resources effectively and efficiently.

Potential for more than minimal harm · Administration Deficiencies · Tag F0835 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

DEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Potential for more than minimal harm · Administration Deficiencies · Tag F0836 · Complaint inspection · Deficient, Provider has date of correction (Mar 17, 2026)

FKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

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

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0730 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Potential for more than minimal harm · Administration Deficiencies · Tag F0941 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0942 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Potential for more than minimal harm · Administration Deficiencies · Tag F0944 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0945 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EProvide training in compliance and ethics.

Potential for more than minimal harm · Administration Deficiencies · Tag F0946 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

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

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

EProvide behavior health training consistent with the requirements and as determined by a facility assessment.

Potential for more than minimal harm · Administration Deficiencies · Tag F0949 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

DVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0729 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

DAdminister the facility in a manner that enables it to use its resources effectively and efficiently.

Potential for more than minimal harm · Administration Deficiencies · Tag F0835 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2026)

FEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Potential for more than minimal harm · Administration Deficiencies · Tag F0837 · Complaint inspection · Deficient, Provider has date of correction (Feb 12, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Feb 12, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Feb 12, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2026)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2026)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2026)

EReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

EEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Aug 4, 2025)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jun 9, 2025)

EEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0726 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Jun 9, 2025)

EImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Jun 9, 2025)

EEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0809 · Deficient, Provider has date of correction (Jun 9, 2025)

EProvide or get specialized rehabilitative services as required for a resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0825 · Deficient, Provider has date of correction (Jun 9, 2025)

EHire a qualified full-time social worker in a facility with more than 120 beds.

Potential for more than minimal harm · Administration Deficiencies · Tag F0850 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Administration Deficiencies · Tag F0868 · Deficient, Provider has date of correction (Jun 9, 2025)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0882 · Deficient, Provider has date of correction (Jun 9, 2025)

DNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0569 · Deficient, Provider has date of correction (Jun 9, 2025)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Jun 9, 2025)

DNot require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0620 · Deficient, Provider has date of correction (Jun 9, 2025)

DNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (Jun 9, 2025)

DNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Deficient, Provider has date of correction (Jun 9, 2025)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Jun 9, 2025)

DProvide care or services that was trauma informed and/or culturally competent.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0699 · Deficient, Provider has date of correction (Jun 9, 2025)

DObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0710 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0740 · Deficient, Provider has date of correction (Jun 9, 2025)

DProvide medically-related social services to help each resident achieve the highest possible quality of life.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0745 · Deficient, Provider has date of correction (Jun 9, 2025)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Jun 9, 2025)

DKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Deficient, Provider has date of correction (Jun 9, 2025)

DGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 · Deficient, Provider has date of correction (Jun 9, 2025)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0660 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

DEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Complaint inspection · Deficient, Provider has date of correction (Apr 14, 2025)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Feb 15, 2025)

DNot require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0620 · Complaint inspection · Deficient, Provider has date of correction (Feb 15, 2025)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Nov 6, 2024)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Nov 6, 2024)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Aug 22, 2024)

DMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Complaint inspection · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jun 17, 2024)

EReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Jun 17, 2024)

EHonor the resident's right to organize and participate in resident/family groups in the facility.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0565 · Deficient, Provider has date of correction (Jun 17, 2024)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Jun 17, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0554 · Deficient, Provider has date of correction (Jun 17, 2024)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Jun 17, 2024)

DProvide 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Deficient, Provider has date of correction (Jun 17, 2024)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Administration Deficiencies · Tag F0868 · Deficient, Provider has date of correction (Jun 17, 2024)

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

Potential for more than minimal harm · Environmental Deficiencies · Tag F0919 · Deficient, Provider has date of correction (Jun 17, 2024)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Complaint inspection · Deficient, Provider has date of correction (Jan 22, 2024)