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Deficiency Records for Affinity Healthcare

A list of the most recent deficiencies for Affinity Healthcare. 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 Affinity Healthcare. 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?
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-07-11 2023-10-13 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-07-11 2023-08-21 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-07-03 2023-08-14 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-07-03 2023-08-14 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2023-07-03 2023-08-14 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-07-03 2023-08-14 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-07-03 2023-08-14 N
Respond appropriately to all alleged violations. Health 2023-07-03 2023-08-14 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 2023-07-03 2023-08-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-07-03 2023-08-14 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-07-03 2023-08-14 N
Provide activities to meet all resident's needs. Health 2023-07-03 2023-08-14 N
Assist a resident in gaining access to vision and hearing services. Health 2023-07-03 2023-08-14 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-03 2023-08-14 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 2023-07-03 2023-08-14 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-07-03 2023-08-14 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 2023-07-03 2023-08-14 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 2023-07-03 2023-08-14 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 2023-07-03 2023-08-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-07-03 2023-08-14 N
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Health 2023-07-03 2023-08-14 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 2023-07-03 2023-08-14 N
Provide and implement an infection prevention and control program. Health 2023-07-03 2023-08-14 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-07-03 2023-08-14 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 2023-02-16 2023-03-24 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-02-16 2023-03-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-16 2023-03-24 Y
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 2022-02-24 2022-04-11 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-02-24 2022-04-11 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-02-24 2022-04-11 Y
Provide bedrooms that don't allow residents to see each other when privacy is needed. Health 2022-02-24 2022-04-11 Y
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2020-02-20 2021-02-15 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2020-02-20 2021-02-15 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-02-20 2021-02-15 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2020-02-20 2021-02-15 N
Provide and implement an infection prevention and control program. Health 2020-02-20 2021-02-15 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2020-02-20 2021-02-15 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-01-04 2021-01-26 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2021-01-04 2021-01-26 N
Establish policies and procedures for volunteers. Fire Safety 2021-01-04 2021-01-26 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-01-04 2021-01-26 N
Establish roles under a Waiver declared by secretary. Fire Safety 2021-01-04 2021-01-26 N
Establish emergency prep training and testing. Fire Safety 2021-01-04 2021-01-26 N
Establish staff and initial training requirements. Fire Safety 2021-01-04 2021-01-26 N
Conduct testing and exercise requirements. Fire Safety 2021-01-04 2021-01-26 N
Meet other general requirements that are deficient. Fire Safety 2021-01-04 2021-01-26 N
Have an enclosure around a vertical opening shaft. Fire Safety 2021-01-04 2021-01-26 N
Install an approved automatic sprinkler system. Fire Safety 2021-01-04 2021-01-26 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-01-04 2021-01-26 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-01-04 2021-01-26 N
Give the resident's representative the ability to exercise the resident's rights. Health 2020-02-20 2020-11-11 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 N
Keep residents' personal and medical records private and confidential. Health 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 N
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. Health 2020-02-20 2020-11-11 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2020-02-20 2020-11-11 N
Ensure each resident receives an accurate assessment. Health 2020-02-20 2020-11-11 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-02-20 2020-11-11 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-02-20 2020-11-11 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2020-02-20 2020-11-11 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 N
Observe each nurse aide's job performance and give regular training. Health 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 N
Provide or obtain dental services for each resident. Health 2020-02-20 2020-11-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-20 2020-11-11 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2020-02-20 2020-11-11 N
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Health 2020-02-20 2020-11-11 N
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 2020-02-20 2020-11-11 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 2020-02-20 2020-11-11 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-05-02 2019-05-28 N
Have restrictions on the use of portable space heaters. Fire Safety 2019-05-02 2019-05-28 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2019-03-19 2019-05-14 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-03-19 2019-05-14 N
Assist a resident in gaining access to vision and hearing services. Health 2019-03-19 2019-05-14 N
Provide or obtain dental services for each resident. Health 2019-03-19 2019-05-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-03-19 2019-05-14 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 2019-03-19 2019-05-14 N

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