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Deficiency Records for Lewis and Clark Gardens
A list of the most recent deficiencies for Lewis and Clark Gardens. 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 Lewis and Clark Gardens. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-26 | 2024-07-17 | Y |
| 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 | 2024-06-26 | 2024-07-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-15 | 2024-07-17 | Y |
| 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 | 2024-05-15 | 2024-07-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-15 | 2024-05-31 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-27 | 2024-02-05 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-27 | 2024-02-05 | 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 | 2023-12-27 | 2024-02-05 | Y |
| 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 | 2023-12-27 | 2024-02-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-27 | 2024-02-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-27 | 2024-02-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-27 | 2024-02-05 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-02 | 2023-01-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-02 | 2023-01-06 | 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 | 2022-12-02 | 2023-01-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-02 | 2023-01-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-02 | 2023-01-06 | 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 | 2022-12-06 | 2023-01-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-18 | 2022-09-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-18 | 2022-09-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-18 | 2022-09-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-25 | 2022-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-25 | 2022-09-22 | 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 | 2022-07-25 | 2022-09-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-25 | 2022-04-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2021-12-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2021-12-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-18 | 2021-12-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-11-18 | 2021-12-29 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-06-18 | 2019-07-31 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-06-18 | 2019-07-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-18 | 2019-07-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-18 | 2019-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-18 | 2019-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| 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 | 2019-06-18 | 2019-07-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-18 | 2019-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-18 | 2019-07-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Meet other general requirements. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-08 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-08 | Not Fixed | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-08 | Not Fixed | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-08 | Not Fixed | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-08-08 | Not Fixed | 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 | 2024-08-08 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-08 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-08 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-08 | Not Fixed | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Meet other general requirements. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-08 | Not Fixed | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-08 | Not Fixed | N |
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