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Calibre Post Acute, Llc

Inspection Results

Nursing Homes New Mexico Las Cruces Calibre Post Acute, Llc

Calibre Post Acute, Llc has been cited for a total of 168 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Calibre Post Acute, Llc.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 74 nursing homes in New Mexico with a total of 5,691 deficiencies resulting in an average of 76.91 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-08-03
Corrected:
2023-09-02
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Notify 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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Provide care or services that was trauma informed and/or culturally competent.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
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.
Category:
Pharmacy Service Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2023-08-03
Corrected:
2023-09-02
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Notify 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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Implement 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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Notify 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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Implement 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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-09-09
Corrected:
2022-10-07
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Implement 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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Implement 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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-04-08
Corrected:
2022-05-24
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-11-10
Corrected:
2021-12-03
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-12-03
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-12-03
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-12-03
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-10-22
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-12-03
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-12-03
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-09-17
Corrected:
2021-12-03
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-06-24
Corrected:
2021-08-09
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-12-03
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Ensure 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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
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.
Category:
Pharmacy Service Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-12-03
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-06-24
Corrected:
2021-08-09
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-12-03
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Ensure 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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
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.
Category:
Pharmacy Service Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-12-03
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
Y
Standard:
Y
Survey Date:
2021-06-24
Corrected:
2021-08-09
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Notify 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.
Category:
Resident Rights Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Assess the resident when there is a significant change in condition
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-28
Implement 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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-28
Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-15
Corrected:
2020-02-21

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