Minot Health and Rehab

    600 Main St S, Minot, ND 58701
    • Assisted Living
    • Skilled Nursing

    Consistently attentive compassionate care provided

    I'm very pleased with the care my mom receives - the director of nursing is amazing and available 24/7. The staff are helpful, attentive and compassionate; they quickly provided a blanket and kept my mom clean, groomed, and comfortable, and her needs are consistently met.

    Loved one of resident
    Jul 2026

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    2.92·(12)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.6
    • Staff

      2.6
    • Meals

      2.9
    • Amenities

      2.9
    • Value

      2.9

    Pros

    • Accessible, responsive director of nursing
    • Compassionate and attentive nursing staff
    • Staff who provide individualized, above‑and‑beyond care
    • Effective leadership and administrative communication
    • Prompt basic comfort measures (e.g., blankets, grooming)
    • Clean personal appearance and grooming for residents

    Cons

    • Incontinence‑care delays and sanitation concerns
    • Unreliable response to call lights and resident requests
    • Inconsistent staffing levels and staffing shortages
    • Inconsistent staff professionalism and communication tone
    • Gaps in emergency response and family notification procedures
    • Variable rehabilitation program effectiveness
    • Temperature control and comfort issues in common/dining areas
    • Allegations of information withholding by leadership
    • Operational priorities that may favor administration over bedside care

    Summary of reviews

    Reviews indicate a facility with sharply mixed experiences: some families describe attentive, compassionate caregivers and an accessible director of nursing, while others report significant operational and care-delivery problems. The pattern is one of high variability — individual staff members and leaders are praised for responsiveness and personalized attention, but persistent service-level weaknesses are also described.

    Care quality shows notable inconsistency. Several accounts point to delays in attending to resident needs, including incontinence‑care delays and slow response to call lights. At the same time, other families reported that basic grooming and comfort needs (clothing, hair, nails, blankets) were met promptly, indicating variability in bedside care rather than uniformly poor practice. Staffing appears to be a central driver of this variability: reviewers described periods with insufficient staff on duty and uneven distribution of workload, which aligns with reports of delayed responses and inconsistent rehabilitation outcomes.

    Staff conduct and communication are similarly mixed. Many families praised caregivers who demonstrate compassion and go beyond expected duties; others described curt or rude interactions and unclear communication about residents’ status and location. There are also concerns about how the facility manages clinical incidents and family notification: examples include delays or difficulties in arranging emergency transport and gaps in timely, transparent updates to families.

    Rehabilitation and program effectiveness were described as uneven. Some reviewers characterized the rehab services as inadequate relative to expectations, while others did not comment or noted positive interactions. The dining and common-area environment received limited specific feedback, but there were comments about temperature control in the dining room that caused discomfort for a resident; conversely, staff were able to provide immediate comfort items when asked.

    Leadership and management receive both positive and negative remarks. Several families praised leadership for good communication and a responsive director of nursing who is available across shifts. At the same time, there are serious allegations from some reviewers that leadership withheld information from external parties; these kinds of claims suggest families should review inspection records and incident logs as part of due diligence. Additionally, some reviewers perceived an operational emphasis on administrative/financial processes over consistent bedside care.

    For prospective residents and families: consider an in-person visit during peak and off-peak hours to observe staffing levels, call-light response times, and mealtime/ dining-room conditions. Ask for current staffing ratios, recent state survey and corrective-action reports, policies for incontinence care and emergency transport, and metrics or examples of rehabilitation outcomes. Meet the director of nursing and frontline staff when possible to assess communication style and consistency. These steps will help determine whether the facility’s strengths align with your relative’s care needs and whether the variability described in reviews is likely to affect day‑to‑day care.

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    Medicare Ratings

    2·/ 5
    Cited by CMS for abuse, or potential for abuse, on its most recent survey cycle.
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Map showing location of Minot Health and Rehab

    Minot Health and Rehab is located at 600 Main St S, Minot, ND, 58701.

    About Minot Health and Rehab

    Minot Health and Rehab sits right in Historic Downtown Minot, offering a view of the city and always staying open around the clock. This place is set up for folks who need either short-term help after a hospital stay, surgery, or accident, or those who need long-term nursing because they can't live alone anymore. They offer things like skilled nursing care 24/7, physical therapy, speech therapy, occupational therapy, hospice care, memory care, and specialized treatments such as IV antibiotics, PICC management, tracheostomy care, tube feedings, and wound care. Residents and families can expect a safe and comfortable place, with activities, outings, meals, and therapy services included to make daily life better. They have a group of therapists, including Colleen L. Feller, Melissa Lee Sober, and Stephanie Diane Palmer, who focus on mobility and recovery with personalized plans for each resident, and the team also helps people with respiratory therapy, swallow studies, and other medical needs. The facility's got 74 to 114 beds, depending on the specific count used, and they average about 3.32 nurse hours per resident a day, with skilled nursing staff available. The staff tries to treat everyone, including visitors and family, like guests in their home. They handle rehabilitation, assisted living, home health, and even brain injury rehab, working closely with doctors and providing in-house visits, pharmacy support, and things like daily weights, glucose monitoring, nebulizer treatments, and infection control. The North Shore Healthcare group oversees the facility, and Farrah Hassan is the executive director. There have been state and federal reports of safety issues in the past, with some deficiencies noted for infection control and overall care, and the nurse turnover rate runs high at about 68.4%. Even so, Minot Health and Rehab has had some recognition from the Centers for Medicare and Medicaid Services as deficiency free at least once, but families will want to review inspection and staffing history for the most up-to-date picture. The center has been around since 2015 and runs as a for-profit company, managing both direct owners and staff. While some information about staff and management isn't public, the most important part is the wide range of services for people with many different care needs, whether that's simply short-term rehab, longer nursing care, or help with medical and memory problems.

    People often ask...

    Minot Health and Rehab offers assisted living and skilled nursing.

    The full address for this community is 600 Main St S, Minot, ND 58701.

    No, Minot Health and Rehab does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In North Dakota, Health & Human Services' Health Facilities unit licenses care facilities and publishes the health and life-safety deficiencies found during inspections.

    License numberSNF-minot-health-and-rehab-minot
    Facility typeSkilled Nursing Facility

    Inspection Reports

    54

    Reports

    8

    Type A Citations

    0

    Type B Citations

    0

    Complaints

    16

    Years

    24 Nov 2025Inspection
    Investigated a complaint and found that a resident was left on a bedside commode for hours without a call light or monitoring, resulting in injury, and the incident was not reported as required.
    • 42 CFR 483.12Freedom from Abuse and Neglect
    • 42 CFR 483.12(c)Reporting of Alleged Violations
    23 Jun 2025Life Safety
    Found that smoke detectors were not sensitivity-tested in accordance with NFPA 72, and no records showed the required two-year testing.
    • NFPA 101 19.3.4.5; 9.6.2.10.1; NFPA 72 14.4.5.3Smoke Detection System Testing and Sensitivity
    10 Jun 2025Inspection
    Identified multiple deficiencies related to the environment, discharge/bed-hold communications, accurate resident assessments, care planning, medication-related processes, bathing, and hospice documentation.
    • CFR 483.10(i)Safe/Clean/Comfortable/Homelike Environment
    • CFR 483.15(c)(2)–(6); 483.21(c)(2)(i)–(iii); 483.15(d)–(e)Discharge Process
    • CFR 483.20(g)–(j); 483.20(i)Accuracy of Assessments
    • CFR 483.21(b)(3); 483.20(j); 483.24; 418.112Services Provided Meet Professional Standards
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.70(n)(4); 483.70(n)(3); 483.70(n)(2); hospice policyHospice Services
    19 Feb 2025Inspection
    Found no deficiencies during complaint investigations.
    31 Dec 2024Inspection
    Found abuse-related deficiencies after investigation, concluding residents were not protected from sexual abuse and mental abuse.
    • CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    02 Dec 2024Inspection
    Identified that a resident experienced non-consensual sexual contact by another resident, indicating failure to protect residents from abuse.
    • 42 CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    16 May 2024Inspection
    Investigated a complaint and found multiple deficiencies in notifying residents/POA and physicians about changes in condition, accurate assessment coding, and medication and wound care practices.
    • 483.10(g)(14)-(15)Notify of Changes
    • 483.20(g)Accuracy of Assessments
    • 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • 483.25(b)(1)(i)-(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
    • 483.45(g)(h)(1)(2)Label/Store Drugs and Biologicals
    14 May 2024Life Safety
    Identified failure to conduct a required PM shift fire drill during the third quarter of the past year, affecting one of twelve drills.
    • NFPA 101 Fire Drills (19.7.1.4-19.7.1.7)Fire Drills
    09 May 2023Life Safety
    Identified noncompliance with NFPA 99 due to an unprotected light switch in an oxygen storage room containing more than 300 cubic feet of oxygen.
    • NFPA 99, A.5.1.3.3.2(5)Gas Equipment - Cylinder and Container Storage
    09 May 2023Inspection
    Found deficiencies in resident rights, privacy, quality of care, infection control, and restorative nursing that affected multiple residents.
    • CFR 483.10Resident Rights/Exercise of Rights
    • CFR 483.10(h)Personal Privacy/Confidentiality of Records
    • CFR 483.25Quality of Care
    • CFR 483.80Infection Prevention & Control
    • CFR 483.25(c)Mobility/ROM
    21 Nov 2022Life Safety
    Found deficiencies in smoke barrier doors, GFCI protection for receptacles near sinks, and emergency generator testing per NFPA standards.
    • NFPA 101, 2012 Edition, 19.3.7.6; 19.3.7.8; 19.3.7.9Smoke barrier doors
    • NFPA 70, 210.8Electrical receptacles near wet locations
    • NFPA 99; NFPA 110Emergency power system maintenance and testing
    09 Nov 2022Inspection
    Identified deficiencies in billing notices, medication labeling/administration, oxygen management, and COVID-19 vaccination contingency plans.
    • CFR 483.10(g)(17)-(18)Medicaid/Medicare Coverage/Liability Notice
    • CFR 483.21(b)(3)(i)Comprehensive Care Plans – Meet Professional Standards
    • CFR 483.45(g)-(h)(1)-(2)Label/Store Drugs and Biologicals
    • CFR 483.80(i)COVID-19 Vaccination of Facility Staff
    07 Sept 2022Inspection
    Investigated a complaint and identified a deficiency due to improper restraints during van transport, resulting in a resident fall and serious injuries.
    • CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
    01 Jun 2022Life Safety
    Identified failure to separate hazardous areas from other spaces with smoke-resisting partitions and self-closing doors; a corridor door to a Soiled Utility Room lacked a self-closing device.
    • NFPA 101, 19.3.2.1; 19.3.5.9Hazardous Areas - Enclosure
    26 May 2022Inspection
    Identified multiple deficiencies related to resident notices, bed-hold and transfer communications, and medication administration practices.
    • §483.10(g)(17) and §483.10(g)(18)Medicaid/Medicare Coverage/Liability Notice
    • §483.15(c)(3)-(6) and §483.15(c)(8)Notice Requirements Before Transfer/Discharge
    • §483.15(d)(1) and §483.15(d)(2)Bed-Hold Notice Upon Transfer
    • §483.21(b)(3)(i)Comprehensive Care Plans
    14 Mar 2022Inspection
    Found no deficiencies. The concerns were unsubstantiated.
    01 Feb 2022Inspection
    Identified failure to follow physician orders for weekly hemoglobin testing, which led to a transfer for a blood transfusion.
    • 42 CFR 483.21(b)(3)(i)Comprehensive Care Plans
    04 Nov 2021Inspection
    Investigated multiple deficiencies across resident care, including failure to notify representatives after changes, privacy lapses, inadequate adherence to professional standards, insufficient ADL support, nutrition concerns, safety issues, medication/recordkeeping problems, and COVID-19 testing gaps.
    • §483.10(g)(14)-(15)Notify of Changes (Injury/Decline/Room, etc.)
    • §483.10(h)(1)-(3)Personal Privacy/Confidentiality of Records
    • §483.21(b)(3)(i)Services Provided Meet Professional Standards
    • §483.24(a)(2)ADL Care Provided for Dependent Residents
    • §483.25Quality of Care
    • §483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
    • §483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
    • §483.35(a)(1)-(2)Sufficient Nursing Staff
    • §483.45(g)-(h)Label/Store Drugs and Biologicals
    • §483.60(i)Food Procurement, Store/Prepare/Serve-Sanitary
    • §483.20(f)(5), §483.70(i)Resident Records - Identifiable Information
    • §483.80(h)COVID-19 Testing-Residents & Staff
    02 Nov 2021Life Safety
    Identified multiple life-safety deficiencies related to emergency lighting, cooking facilities, fire alarm maintenance, portable extinguishers, and essential electrical systems.
    • NFPA 101 – Emergency Lighting (7.9.3.1.1; 18.2.9.1; 19.2.9.1)Emergency Lighting
    • NFPA 96 – Ventilation Control and Fire Protection of Commercial Cooking Operations; NFPA 17A – Wet Chemical Extinguishing SystemsCooking Facilities
    • NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
    • NFPA 10Portable Fire Extinguishers
    • NFPA 99 6.4.1.1.17Electrical Systems - Essential Electric System
    • NFPA 99; NFPA 110; NFPA 111; NFPA 70Electrical Systems - Essential Electric System Maintenance and Testing
    04 Aug 2021Inspection
    Found deficiencies in wound care management, unsafe transfer practices using lifts, and lapses in infection control during dressing changes.
    • CFR 483.21(b)(3)(i)Comprehensive Care Plans
    • CFR 483.25(d)Accidents
    • CFR 483.80(a)Infection Control
    13 Jul 2021Inspection
    Found deficiencies in providing reasonable accommodations for a resident, ensuring accurate assessments, following professional standards in care planning, timely nail care, skin protection, and infection control.
    • CFR 483.10(e)(3)Accommodations of Needs
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(b)(3)(i)Professional Standards of Care
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25(b)(1)(i)(ii)Treatment/ Svcs to Prevent/Heal Pressure Ulcers
    • CFR 483.80(a)(1)-(a)(4), (e), (f); 483.80Infection Prevention & Control
    14 Jun 2021Life Safety
    Identified multiple life-safety deficiencies across egress signage, emergency lighting, cooking facilities, fire alarm and sprinkler systems, portable extinguishers, electrical systems, fire drills, and the emergency generator. These findings indicate violations were cited.
    • NFPA 101; 19.2.2.2.4(2); 7.2.1.6.1.1(4)Egress Doors
    • NFPA 101; 18.2.9.1; 7.9.3.1.1; 19.2.9.1Emergency Lighting
    • NFPA 101; 18.3.2.5.1-5; NFPA 96Cooking Facilities
    • NFPA 101; NFPA 70; NFPA 72; 9.6.1.3; 9.6.1.5; 19.3.4.1Fire Alarm System - Testing and Maintenance
    • NFPA 25; 19.7.6; 4.6.12; NFPA 25 4.6Sprinkler System - Maintenance and Testing
    • NFPA 10; NFPA 19.3.5.12; NFPA 9.7.4.1; NFPA 7.2.1.1Portable Fire Extinguishers
    • NFPA 70; 210.8; 210.8(B)Utilities - Gas and Electric
    • NFPA 101; 19.7.1.4-19.7.1.7Fire Drills
    • NFPA 99; NFPA 110; NFPA 111; NFPA 70; 700.10Electrical Systems - Essential Electric System
    24 May 2021Inspection
    Investigators found multiple deficiencies across resident rights, care planning, staffing, nutrition, and infection control, indicating noncompliance with federal requirements.
    • CFR(s): 483.10(a)(1) 483.10(a)(2) 483.10(b)(1) 483.10(b)(2)Resident Rights/Exercise of Rights
    • CFR(s): 483.10(e)(3)Reasonable Accommodations Needs/Preferences
    • CFR(s): 483.10(g)(10)(11)Right to Survey Results/Advocate Agency Info
    • CFR(s): 483.10(c)(6) 483.10(c)(8) 483.10(g)(12) 483.10(g)(15)Ad Advanced Directives/Right to Refuse/Discontinue Treatment
    • CFR(s): 483.10(g)(14)(15)Notification of Changes
    • CFR(s): 483.10(j)Grievances
    • CFR(s): 483.15(d)(1) 483.15(d)(2)Bed-hold Policy/Notice Upon Transfer
    • CFR(s): 483.20(g)Accuracy of Assessments
    • CFR(s): 483.20(e)(1)(2)Coordination PASARR and Assessments
    • CFR(s): 483.21(b)(1) 483.21(b)(2) 483.21(b)(3)(ii)(iii)Care Plan Development/Content
    • CFR(s): 483.21(b)(2)Care Plan Timing/Revision
    • CFR(s): 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • CFR(s): 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR(s): 483.25Quality of Care
    • CFR(s): 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
    • CFR(s): 483.25(i)Respiratory Care/Suctioning
    • CFR(s): 483.35(a)(1)(2)Sufficient Nursing Staff
    • CFR(s): 483.35(a)(3)(4)(c)Competent Nursing Staff/Nurse Aide Competency
    • CFR(s): 483.35(d)(7)Nurse Aide In-Service/Education
    • CFR(s): 483.45(e)Free from Unnecessary Psychotropic Meds/PRN Use
    • CFR(s): 483.45(f)(2)Residents Free from Significant Med Errors
    • CFR(s): 483.45(g)(h)Labeling/Storing Drugs and Biologics
    • CFR(s): 483.75(g)(2)QAPI/QAA Improvement Activities
    • CFR(s): 483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
    13 Oct 2020Inspection
    Verified compliance with infection control requirements during a focused COVID-19 survey; eight residents were COVID-19 positive.
    23 Sept 2020Inspection
    Identified deficiencies in infection prevention and control practices and in COVID-19 testing documentation.
    • 42 CFR 483.80Infection Prevention & Control
    • 42 CFR 483.80(h)COVID-19 Testing-Residents & Staff
    01 Sept 2020Inspection
    Found deficiencies in behavioral health assessment and care planning for a resident at risk of self-harm and in infection prevention/control practices affecting multiple residents.
    • 483.40Behavioral health services
    • 483.80Infection Prevention & Control
    17 Mar 2020Inspection
    Verified no deficiencies were found during a COVID-19 focused infection control survey conducted on 2020-03-16.
    21 Oct 2019Inspection
    Investigated widespread care deficiencies across resident rights, medical treatments, nutrition, infection control, and staffing, with multiple residents affected by unsafe practices.
    • CFR 483.10(f)Self-Determination
    • 42 CFR 483.10(g)(17)-(18)Medicare/Medicaid Coverage/Liability Notice
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(b)Care Plan Timing and Revision
    • CFR 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25(g)Nutrition/Hydration Status Maintenance
    • CFR 483.25(i)Respiratory Care and Suctioning
    • CFR 483.35Sufficient Nursing Staff
    • CFR 483.45(f)Residents are Free of Significant Medication Errors
    • CFR 483.60(d)Nutritive Value/Appearance/Temperature
    • CFR 483.80Infection Prevention & Control
    31 Jul 2019Inspection
    Identified multiple deficiencies across care planning, medication management, nutrition, wound care, supervision, and oxygen administration that affected resident safety and quality of care.
    • 42 CFR 483.21(b)Care Plan Timing and Revision
    • 42 CFR 483.21(b)(3)Services Provided Meet Professional Standards
    • 42 CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • 42 CFR 483.25(b)Skin Integrity
    • 42 CFR 483.25(d)ADL Care/Supervision to Prevent Accidents
    • 42 CFR 483.25(g)Nutrition/Hydration Status Maintenance
    • 42 CFR 483.25(i)Respiratory Care and Oxygen Administration
    23 Jul 2019Life Safety
    Identified multiple deficiencies in fire safety, emergency preparedness, and life-safety systems, including lack of annual drills, improper exit hardware, misinstalled sprinklers, untested smoke detectors, and overdue generator testing.
    • CFR 483.73(d)(2)Testing requirements for emergency preparedness
    • NFPA 101; NFPA 80; 7.2.1; 8.3.3.1Means of Egress - General
    • NFPA 101; 18.2.2.2.5.1; 18.2.2.2.6; 19.2.2.2.5.1; 19.2.2.2.6Egress Doors
    • NFPA 101; NFPA 72; NFPA 70; 21.2Fire Alarm System - Installation
    • NFPA 72; 19.3.4.5; 9.6.2.10.1.1Smoke Detection
    • NFPA 13; 9.1.1.7Sprinkler System - Installation
    • NFPA 25; 4.1.4.1; 9.7; NFPA 25Sprinkler System - Maintenance and Testing
    • NFPA 10; 9.7.4.1; 6.1.3.8.1Portable Fire Extinguishers
    • NFPA 110; NFPA 25; NFPA 70Electrical Systems - Essential Electric System
    11 Jun 2019Inspection
    An onsite complaint review identified multiple deficiencies across resident rights, care planning, infection control, nutrition, medication administration, and supervision, indicating systematic shortcomings in care and environment. Numerous residents were impacted by failures to honor dignity, communicate changes, properly document care, and follow clinical orders.
    • CFR 483.10Resident Rights/Exercise of Rights
    • CFR 483.10(g)(14)Notify of Changes
    • CFR 483.10(i)Safe Environment
    • CFR 483.10(j)Grievances
    • CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25Quality of Care
    • CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
    • CFR 483.25(i)Respiratory Care and Suctioning
    • CFR 483.30(c)Physician Visits-Frequency/Timeliness/Alt NPP
    • CFR 483.45(f)Residents are Free of Significant Medication Errors
    • CFR 483.60Qualified Dietary Staff
    • CFR 483.80Infection Prevention & Control
    16 Aug 2018Inspection
    Investigated numerous deficiencies in resident rights, care planning, assessments, transfers, medications, nutrition, dialysis, and infection control following a short-term survey conducted in August 2018.
    • 42 CFR 483.10Resident Rights/Exercise of Rights
    • 42 CFR 483.10(g)Advance Directives
    • 42 CFR 483.15Transfer and Discharge
    • 42 CFR 483.15Notice before transfer
    • 42 CFR 483.15(d)Bed-Hold Notice Upon Transfer
    • 42 CFR 483.20(g)Accuracy of Assessments
    • 42 CFR 483.20(e)Coordination
    • 42 CFR 483.21(a)Baseline Care Plans
    • 42 CFR 483.21(b)Comprehensive Care Plans
    • 42 CFR 483.25Services Provided Meet Professional Standards
    • 42 CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • 42 CFR 483.60(d)Swallow Safety
    • 42 CFR 483.25(d)Accidents
    • 42 CFR 483.35(d)Nurse Aide In-Service
    • 42 CFR 483.45(c)(1)-(5)Drug Regimen Review
    • 42 CFR 483.45(d)Unnecessary Drugs
    • 42 CFR 483.60(c)Menus Meet Resident Needs/Prep in Advance/Followed
    • 42 CFR 483.60(d)Nutritive Value/Palatable/Temperature
    • 42 CFR 483.70(g)Use of Outside Resources
    • 42 CFR 483.80Infection Control
    09 Jul 2018Life Safety
    Identified multiple life-safety deficiencies including obstructed means of egress, incomplete fire alarm testing, and improper timing of fire drills.
    • NFPA 101 Means of Egress - General (7.1.10.1, 7.3.2.2)Means of Egress - General
    • NFPA 70; NFPA 72; 9.6.1.3; 9.6.1.5; 19.3.4.1Fire Alarm System - Testing and Maintenance
    • NFPA 101 Fire Drills 19.7.1.4; 19.7.1.6; 19.7.1.7; 4.7.4; 4.7.6Fire Drills
    26 Jul 2017Inspection
    Investigated multiple deficiencies in resident care, including failure to notify physicians about held medications, incomplete assessments after changes in condition, inadequate participation in planning care, and lapses in nutrition, oxygen, and medication management.
    • 483.10(g)(14)NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)
    • 483.20(b)(2)(ii)COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE
    • 483.10(c)(2)RIGHT TO PARTICIPATE IN PLANNING CARE-REVISE CP
    • 483.21(b)(2)COMPREHENSIVE CARE PLANS
    • 483.21(b)(3)(i)SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
    • 483.21(b)(3)(i)MEDICATION VIA GASTROSTOMY TUBE
    • 483.25(c)(3) and 483.25(n)(3)MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE
    • 483.25(b)(2)(f)(g)(5)(h)(i)(j)TREATMENT/CARE FOR SPECIAL NEEDS
    • 483.45(b)(2)(3)(g)(h)DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS
    26 Jul 2017Life Safety
    Identified failure to maintain the automatic sprinkler system, with inspections not conducted for the past year, risking fire protection reliability.
    • 19.7.6, 4.6.12, NFPA 25, 5.1.1.2Automatic sprinkler systems - maintenance and testing
    12 Jan 2017Inspection
    Investigated a wide range of deficiencies across resident care, including notification of changes, care planning, hydration, hygiene, and environmental controls.
    • 483.10(g)(14)Notify of changes (injury/decline/room, etc)
    • 483.10(e)(3)Reasonable accommodation of needs/preferences
    • 483.10(c)(2); 483.21(b)(2)Right to participate planning care; Comprehensive Care Plans
    • 483.24; 483.25(k)(l)Provide care/services for highest well being
    • 483.25(b)(1)Treatment/Service to prevent/heal pressure sores
    • 483.25(e)(1)-(3)No catheter, prevent UTI, restore bladder
    • 483.25(g)(2)Sufficient fluid to maintain hydration
    • 483.25(d)(1)-(3)No unnecessary drugs
    • 483.80(a)(1)-(4); 483.80(e)(f)Infection control; hand hygiene
    • 483.90(h)(2)Adequate outside ventilation - window/mechanical
    10 Jan 2017Life Safety
    Identified multiple life-safety deficiencies across egress, electrical, detection, sprinkler, and building-system areas with incomplete risk assessment and lack of required drills.
    • NFPA 101 Means of Egress - General; 7.2.1.4.3.1Means of Egress - General
    • NFPA 101 Emergency Lighting; 7.9.3; 18.2.9.1, 19.2.9.1Emergency Lighting
    • LSC 4.6.12.3, 4.6.12.4; NFPA 101Protection - Other
    • NFPA 101 Hazardous Areas - Enclosure; 19.3.2.1Hazardous Areas - Enclosure
    • NFPA 72; NFPA 101 19.3.4.5.1; 17.7.4.1Smoke Detection
    • NFPA 25; 9.7.5, 9.7.7, 9.7.8Sprinkler System - Maintenance and Testing
    • NFPA 101 19.3.6.1; 18.3.6.1Corridors - Areas Open to Corridor
    • NFPA 101 Fire Drills; 18.7.1.4-7; 19.7.1.4-7Fire Drills
    • NFPA 99; 4.2Fundamentals - Building System Categories
    • NFPA 99; NFPA 110; 6.4.4.1.1.4; 6.6.2.2.2; 6.6.3.1.1Electrical Systems - Essential Electric System
    04 Aug 2016Inspection
    Investigated a complaint alleging slow call-light responses, inadequate accommodation of resident needs, inaccurate assessments, care-plan issues, and poor pressure-ulcer care.
    • 483.15(c)(6)LISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION
    • 483.15(e)(1)REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES
    • 483.20(g)-(j)ASSESSMENT ACCURACY/COORDINATION/CERTIFIED
    • 483.20(d)(3)RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP
    • 483.25(c)TREAT/SVCS TO PREVENT/HEAL PRESSURE SORES
    04 May 2016Inspection
    Investigations documented multiple deficiencies across resident dignity, safety, medical care, infection control, nutrition, medications, staffing, and environmental practices, showing systemic failures in communication, monitoring, and adherence to care plans.
    • 483.10(b)(11)NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)
    • 483.15(a)DIGNITY AND RESPECT OF INDIVIDUALITY
    • 483.15(c)(6)LISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION
    • 483.15(e)(1)REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES
    • 483.20(k)(3)(i)ASSESSMENT ACCURACY/COORDINATION/CERTIFIED
    • 483.20(k)(3)(i)SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
    • 483.25PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
    • 483.25(l)SUFFICIENT FLUID TO MAINTAIN HYDRATION
    • 483.25(i)FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
    • 483.25(j)MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE
    • 483.25(l)DRUG REGIMEN FREE OF UNNECESSARY DRUGS
    • 483.25(m)(1)NO MEDICATION ERROR RATES OF 5% OR MORE
    • 483.30(e)POSTED NURSE STAFFING INFORMATION
    • 483.60(a),(b)FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY
    • PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH
    • DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON
    • 483.65INFECTION CONTROL, PREVENT SPREAD, LINENS
    03 Feb 2016Life Safety
    Identified multiple life-safety deficiencies: hazardous area doors failed to self-close, there were multiple delayed-egress devices on egress doors, exit corridors were obstructed, and sprinkler system maintenance was inadequate.
    • NFPA 101 Life Safety Code 19.3.2.1Hazardous areas protection
    • NFPA 101 Life Safety Code 19.2.1; 7.2.1.6.1; 7.1.10.1; 7.3.2Means of egress - delayed-egress devices and obstructions
    • NFPA 25; NFPA 13; 19.7.6; 4.6.12; 9.7.5Automatic sprinkler system maintenance
    13 May 2015Inspection
    Inspection identified multiple deficiencies, including safety hazards, breaches of privacy, and improper medication storage and handling.
    • 483.25(h)Free of accident hazards/supervision/devices
    • 483.10(e), 483.75(l)(4)Personal privacy/confidentiality of records
    • 483.60(b), (d), (e)Drug records; labeling/store drugs & biologicals
    25 Mar 2015Inspection
    Investigated allegations of mistreatment and neglect; identified multiple deficiencies related to privacy, dignity, and confidentiality of records.
    • 483.10Personal Privacy/Confidentiality of Records
    • 483.10Dignity/Privacy
    17 Feb 2015Life Safety
    Identified a fire-safety deficiency involving detectors that increased risk of death or injury from fire.
    • NFPA 72NFPA 72 fire detector requirements
    09 Apr 2014Inspection
    Identified multiple deficiencies related to resident rights information, physician communication, medication management, and safe operational practices.
    • Notice of Rights, Rules, Services and ChangesNotice of Rights, Rules, Services and Changes
    • Physician Contact InformationPhysician contact information for residents
    • Provide Care/Services for Highest Well BeingProvide Care/Services for Highest Well Being
    • Drug Regimen Is Free From Unnecessary DrugsDrug Regimen Is Free From Unnecessary Drugs
    • Food Procure, Store/Prepare/Serve—SanitaryFood Procure, Store/Prepare/Serve—Sanitary
    • Resident Records Complete/Accurate/AccessibleResident Records Complete/Accurate/Accessible
    11 Mar 2014Life Safety
    Identified multiple life-safety deficiencies, including an untested duct detector, sprinkler-system maintenance gaps, and obstructed exit corridors.
    • NFPA 101 LIFE SAFETY CODE STANDARDDuct detector testing
    • NFPA 101 LIFE SAFETY CODE STANDARDAutomatic sprinkler systems maintained
    • NFPA 101 LIFE SAFETY CODE STANDARDExits, egress, and visibility
    20 Nov 2013Inspection
    Identified deficiencies related to privacy and confidentiality, including improper handling of resident records and lack of privacy in daily activities.
    • Privacy/Confidentiality of Records
    07 Mar 2013Inspection
    Identified multiple deficiencies involving privacy and dignity, including mishandling of confidential records, exposure of a resident, and inadequate activity programming.
    • Personal privacy and confidentiality of residents' records
    • Binder does not contain required code survey information
    • Privacy/dignity during activities and treatment
    • Care provided without proper attention to resident privacy and safety
    • Inadequate activity program / lack of individualized activities
    14 Feb 2013Life Safety
    Identified life-safety deficiencies including obstructed exit corridors, inadequate fire-resistance barriers, and corroded sprinkler heads needing replacement.
    • NFPA 101 Life Safety Code Standard 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4; 42 CFR 483.70(a)Smoke barriers/fire-resistance barriers not maintained
    • NFPA 101 Life Safety Code Standard 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5Automatic sprinkler system maintenance
    • NFPA 101 Life Safety Code Standard 7.1.10Means of egress obstructed
    11 Apr 2012Inspection
    The facility was found to have several deficiencies affecting resident safety, hygiene and care, including improper environmental conditions and gaps in medication management; multiple pages document ongoing findings.
    • Continued From page 2
    • Continued From page 4
    • Continued From page 5
    • Continued From page 27
    • Continued From page 24
    • Continued From page 28
    21 Feb 2012Life Safety
    Concluded compliance with NFPA 101 Life Safety Code after the Life Safety Code survey. No deficiencies were cited.
    12 May 2011Inspection
    Investigated a complaint and found multiple deficiencies related to resident rights information, privacy during care, assessment documentation, medication management, infection control, and staff practices.
    • Resident rights information
    • Advance directives and related policies
    • Resident assessment documentation
    • Resident assessment documentation (continued) and related guidance
    • Care planning and follow-up (PRN)
    • Infection control / hand hygiene
    • Pharmacy/medication management and related duties
    24 Jan 2011Life Safety
    Investigated deficiencies found regarding door hardware and latching: corridor doors lacked automatic latching, double self-closing doors did not secure the fixed panel, and roller latches were prohibited.
    • 42 CFR 483.70(a); NFPA 101 Life Safety Code, 2000 editionCorridor doors must have automatic latching hardware and proper door closures; roller latches prohibited
    22 Apr 2010Inspection
    An investigation identified multiple deficiencies involving privacy and confidentiality of resident information, resident rights in daily care, and infection control, along with related care processes and staff training.
    • Type APrivacy and confidentiality of residents' records
    • Type AResident rights—privacy/dignity during care
    • Type ADaily living and privacy during meals
    • Type AResident activities and engagement
    • Type ANursing/ADL care training and perineal care
    • Type AInfection control program and practices
    • Type AResident activities and engagement (in-service follow-up)
    • Type AInfection control program and practices (ongoing)
    27 Jan 2010Life Safety
    Found deficiencies in smoke detector testing/maintenance and sprinkler system upkeep, including spacing and obstructions.
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD

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