Inspection visit
Inspection
Citations
14 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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
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.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F712 - Frequency of physician visits
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
F761 - Labeling of Drugs and Biologicals
Ensure 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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0281GeneralS&S Epotential for harm
Install proper backup exit lighting.
FAQ · About this visit
Common questions about this visit
What happened during the December 31, 2024 survey of OUR LADYS CENTER FOR REHABILITATION & HEALTHCARE?
This was a inspection survey of OUR LADYS CENTER FOR REHABILITATION & HEALTHCARE on December 31, 2024. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OUR LADYS CENTER FOR REHABILITATION & HEALTHCARE on December 31, 2024?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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.