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Deficiency Records for Empress Care Center, LLC
A list of the most recent deficiencies for Empress Care Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Empress Care Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide emergency officials' contact information. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-17 | 2024-01-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-22 | 2023-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-22 | 2023-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2023-12-22 | N |
| 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. | Health | 2023-12-22 | 2023-12-22 | N |
| 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. | Health | 2023-12-22 | 2023-12-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-22 | 2023-12-22 | N |
| 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. | Health | 2023-12-22 | 2023-12-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-22 | 2023-12-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-22 | 2023-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-22 | 2023-12-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-22 | 2023-12-22 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-12-22 | 2023-12-22 | N |
| 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. | Health | 2023-12-22 | 2023-12-21 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-09-02 | 2022-10-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-09-02 | 2022-10-02 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-02 | 2022-10-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-02 | 2022-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-02 | 2022-10-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-02 | 2022-10-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-02 | 2022-10-02 | N |
| 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. | Health | 2022-09-02 | 2022-10-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-02 | 2022-10-02 | N |
| 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. | Health | 2022-09-02 | 2022-10-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-10-02 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-02 | 2022-10-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-02 | 2022-10-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-25 | 2019-10-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-25 | 2019-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-25 | 2019-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-25 | 2019-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-25 | 2019-10-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-25 | 2019-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-10-14 | N |
| 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. | Health | 2019-09-25 | 2019-10-14 | N |
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