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Deficiency Records for Community Care Nursing Center
A list of the most recent deficiencies for Community Care Nursing Center. 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 Community Care Nursing Center. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-15 | 2024-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-10 | 2024-05-27 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-17 | 2023-12-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-10 | 2023-12-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-10 | 2023-12-13 | 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 | 2023-08-10 | 2023-12-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-10 | 2023-12-13 | N |
| 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. | Health | 2023-08-10 | 2023-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-12-13 | 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 | 2023-08-10 | 2023-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-10 | 2023-12-13 | 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 | 2023-08-10 | 2023-12-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-08-10 | 2023-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-12-13 | 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 | 2023-08-10 | 2023-12-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-10 | 2023-12-13 | N |
| 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. | Health | 2023-10-04 | 2023-11-15 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-10-04 | 2023-11-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-04 | 2023-11-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-04 | 2023-11-15 | 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 | 2023-10-04 | 2023-11-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-04 | 2023-11-15 | Y |
| Keep all essential equipment working safely. | Health | 2023-10-04 | 2023-11-15 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-10-04 | 2023-11-15 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-08-17 | 2023-09-18 | 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 | 2023-08-17 | 2023-09-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-17 | 2023-09-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-18 | 2023-08-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-16 | 2023-05-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-08 | 2023-03-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-09 | 2023-03-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-09 | 2023-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-09 | 2023-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2023-03-01 | Y |
| 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. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-29 | 2022-11-28 | 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 | 2022-09-29 | 2022-11-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-29 | 2022-11-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-28 | 2022-10-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-28 | 2022-10-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-28 | 2022-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-28 | 2022-10-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-28 | 2022-10-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2022-10-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-28 | 2022-10-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-28 | 2022-10-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-28 | 2022-10-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-28 | 2022-10-26 | 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 | 2022-09-28 | 2022-10-26 | N |
| 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 | 2022-09-28 | 2022-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-28 | 2022-10-26 | N |
| Dispose of garbage and refuse properly. | Health | 2022-09-28 | 2022-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-28 | 2022-10-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-28 | 2022-10-26 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-28 | 2022-10-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-28 | 2022-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-27 | 2022-06-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-27 | 2022-06-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-13 | 2022-03-17 | 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 | 2021-10-13 | 2022-03-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-25 | 2022-03-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-20 | 2022-02-10 | Y |
| 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 | 2022-01-20 | 2022-02-10 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-15 | 2021-11-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-15 | 2021-11-19 | 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 | 2021-10-15 | 2021-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-15 | 2021-11-19 | 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 | 2021-10-15 | 2021-11-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-15 | 2021-11-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-15 | 2021-11-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-15 | 2021-11-19 | Y |
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