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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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