Inspection visit
Inspection
Citations
17 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F584 - Safe Environment
Honor 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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
FAQ · About this visit
Common questions about this visit
What happened during the November 22, 2023 survey of OUR LADYS CENTER FOR REHABILITATION & HEALTHCARE?
This was a inspection survey of OUR LADYS CENTER FOR REHABILITATION & HEALTHCARE on November 22, 2023. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OUR LADYS CENTER FOR REHABILITATION & HEALTHCARE on November 22, 2023?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have properly located and lighted "Exit" signs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.