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Deficiency Records for Enterprise Estates Nursing Center
A list of the most recent deficiencies for Enterprise Estates 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 Enterprise Estates 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? |
|---|---|---|---|---|
| Establish emergency prep training and testing. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-06 | 2024-07-26 | 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 | 2024-02-06 | 2024-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-06 | 2024-07-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-06-05 | 2024-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-17 | 2024-02-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-17 | 2024-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-02-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-17 | 2024-02-16 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-17 | 2024-02-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-17 | 2024-02-16 | 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 | 2024-01-17 | 2024-02-16 | 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 | 2024-01-17 | 2024-02-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-17 | 2024-02-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-17 | 2024-02-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-17 | 2023-08-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-17 | 2023-08-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-17 | 2023-08-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-03 | 2023-05-15 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| 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 | 2022-07-26 | 2022-08-26 | 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 | 2022-07-26 | 2022-08-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-07 | 2022-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-07 | 2022-07-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-07 | 2022-07-07 | 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 | 2022-06-07 | 2022-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-07 | 2022-07-07 | Y |
| Post nurse staffing information every day. | Health | 2022-06-07 | 2022-07-07 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-07 | 2022-07-07 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-07 | 2022-07-07 | Y |
| 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 | 2022-06-07 | 2022-07-07 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-06-07 | 2022-07-07 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-07 | 2022-07-07 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-12-02 | 2021-01-01 | 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 | 2020-12-02 | 2021-01-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-12-02 | 2021-01-01 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2020-11-03 | 2020-11-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-11-03 | 2020-11-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-11-03 | 2020-11-25 | 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 | 2020-11-03 | 2020-11-25 | 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 | 2020-11-03 | 2020-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-11-03 | 2020-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-03 | 2020-11-25 | N |
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