Hospital De La Concepcion INC

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from not rated by CMS to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from not rated by CMS to 2 of 5.

• Star rating

  The CMS staffing star rating changed from not rated by CMS to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0725. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on May 1, 2026.

• Citation F0726. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on May 1, 2026.

• Citation F0582. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on May 1, 2026.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 1, 2026.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on May 1, 2026.

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CMS lists this as a standard inspection.

• Citation K0222. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on May 1, 2026.

• Citation K0291. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on May 1, 2026.

• Citation K0341. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on May 1, 2026.

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• Staffing

  Total nurse staffing reported to CMS went from 2.4 to 1.6 hours per resident per day.

• Name

  CMS lists a new legal business name for this home.

• Listing

  This home now appears in CMS data.

CMS lists this as a standard inspection.

• Citation F0550. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on October 23, 2024.

• Citation F0551. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Give the resident's representative the ability to exercise the resident's rights.

  CMS lists it as corrected on October 11, 2024.

• Citation F0552. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on October 8, 2024.

• Citation F0553. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Allow resident to participate in the development and implementation of his or her person-centered plan of care.

  CMS lists it as corrected on October 8, 2024.

• Citation F0554. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on October 8, 2024.

• Citation F0555. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to choose his or her attending physician.

  CMS lists it as corrected on October 8, 2024.

• Citation F0557. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on October 8, 2024.

• Citation F0558. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on October 8, 2024.

• Citation F0559. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS lists it as corrected on October 8, 2024.

• Citation F0560. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

  CMS lists it as corrected on October 8, 2024.

• Citation F0561. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS lists it as corrected on October 8, 2024.

• Citation F0562. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide immediate access to any resident.

  CMS lists it as corrected on October 8, 2024.

• Citation F0563. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

  CMS lists it as corrected on October 8, 2024.

• Citation F0564. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

  CMS lists it as corrected on October 8, 2024.

• Citation F0565. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on October 8, 2024.

• Citation F0566. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

  CMS lists it as corrected on October 8, 2024.

• Citation F0567. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to manage his or her financial affairs.

  CMS lists it as corrected on October 8, 2024.

• Citation F0568. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

  CMS lists it as corrected on October 8, 2024.

• Citation F0569. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

  CMS lists it as corrected on October 8, 2024.

• Citation F0570. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Assure the security of all personal funds of residents deposited with the facility.

  CMS lists it as corrected on October 8, 2024.

• Citation F0571. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.

  CMS lists it as corrected on October 8, 2024.

• Citation F0572. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Give residents a notice of rights, rules, services and charges.

  CMS lists it as corrected on October 11, 2024.

• Citation F0573. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

  CMS lists it as corrected on October 8, 2024.

• Citation F0574. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: The resident has the right to receive notices in a format and a language he or she understands.

  CMS lists it as corrected on October 8, 2024.

• Citation F0575. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

  CMS lists it as corrected on October 8, 2024.

• Citation F0576. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure residents have reasonable access to and privacy in their use of communication methods.

  CMS lists it as corrected on October 23, 2024.

• Citation F0577. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on October 11, 2024.

• Citation F0578. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on October 11, 2024.

• Citation F0579. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide information about how to apply for and use Medicare and Medicaid benefits.

  CMS lists it as corrected on October 23, 2024.

• Citation F0580. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on October 23, 2024.

• Citation F0583. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on October 8, 2024.

• Citation F0585. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  CMS lists it as corrected on October 8, 2024.

• Citation F0586. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.

  CMS lists it as corrected on October 16, 2024.

• Citation F0604. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on October 23, 2024.

• Citation F0605. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on October 23, 2024.

• Citation F0655. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on October 15, 2024.

• Citation F0790. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide routine and 24-hour emergency dental care for each resident.

  CMS lists it as corrected on September 20, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 8, 2024.

• Citation F0949. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide behavior health training consistent with the requirements and as determined by a facility assessment.

  CMS lists it as corrected on October 23, 2024.

• Citation F0636. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS lists it as corrected on October 23, 2024.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on October 23, 2024.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure 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.

  CMS lists it as corrected on October 3, 2024.

• Citation F0804. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on October 23, 2024.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on September 12, 2024.

• Citation F0806. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on October 3, 2024.

• Citation F0851. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  CMS lists it as corrected on October 10, 2024.

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CMS lists this as a standard inspection.

• Citation K0281. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install proper backup exit lighting.

  CMS lists it as corrected on September 19, 2024.

• Citation K0324. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on September 18, 2024.

• Citation K0918. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on September 16, 2024.

• Citation K0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on October 23, 2024.

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