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Deficiency Records for Imboden Creek Senior Living
A list of the most recent deficiencies for Imboden Creek Senior Living. 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 Imboden Creek Senior Living. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-02 | 2024-05-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-26 | 2024-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-26 | 2024-04-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-05 | 2023-12-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-05 | 2023-12-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-05 | 2023-12-13 | Y |
| Keep all essential equipment working safely. | Health | 2023-12-05 | 2023-12-13 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-12-05 | 2023-12-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-31 | 2023-11-01 | Y |
| 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 | 2023-10-31 | 2023-11-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-23 | 2023-10-14 | 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 | 2023-08-23 | 2023-10-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-23 | 2023-10-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-23 | 2023-10-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-23 | 2023-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-10-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-23 | 2023-10-11 | N |
| 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. | Health | 2023-08-23 | 2023-10-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-23 | 2023-10-11 | 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 | 2023-08-23 | 2023-10-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-23 | 2023-10-11 | 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 | 2023-08-23 | 2023-10-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-23 | 2023-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-23 | 2023-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-23 | 2023-10-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-23 | 2023-10-11 | N |
| Keep all essential equipment working safely. | Health | 2023-08-23 | 2023-10-11 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-08-23 | 2023-10-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-13 | 2023-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-13 | 2023-10-11 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-31 | 2023-09-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-20 | 2023-07-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-20 | 2023-07-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-20 | 2023-07-06 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-05-18 | 2023-05-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-27 | 2023-05-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-27 | 2023-05-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-12 | 2023-05-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-12 | 2023-04-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-12 | 2023-04-21 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-12 | 2023-04-21 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-12 | 2023-04-21 | Y |
| 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. | Health | 2023-04-12 | 2023-04-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-22 | 2023-04-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-22 | 2023-04-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-22 | 2023-04-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-22 | 2023-04-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-22 | 2023-04-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-22 | 2023-04-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-07 | 2023-04-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-07 | 2023-03-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-07 | 2023-03-27 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-07 | 2023-03-27 | Y |
| 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. | Health | 2023-02-14 | 2023-03-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-18 | 2023-02-02 | Y |
| 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 | 2023-01-18 | 2023-02-02 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-01-18 | 2023-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-18 | 2023-02-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-02-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-18 | 2023-02-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-18 | 2023-02-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-11-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-19 | 2022-10-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-03 | 2022-07-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-19 | 2022-07-20 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-03 | 2022-07-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-06-03 | 2022-07-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-03 | 2022-07-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-03 | 2022-07-19 | N |
| 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. | Health | 2022-06-03 | 2022-07-19 | 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 | 2022-06-03 | 2022-07-19 | 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 | 2022-06-03 | 2022-07-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-06-03 | 2022-07-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-03 | 2022-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-03 | 2022-07-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-03 | 2022-07-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-10 | 2022-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-10 | 2022-06-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-10 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-10 | 2022-06-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-10 | 2022-06-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-11 | 2022-05-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-11 | 2022-05-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-15 | 2022-05-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-06 | 2022-04-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-20 | 2021-07-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-20 | 2021-05-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-20 | 2021-05-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-20 | 2021-05-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-20 | 2021-05-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-20 | 2021-05-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-04-20 | 2021-05-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-20 | 2021-05-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-20 | 2021-04-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-08 | 2021-04-23 | N |
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