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Deficiency Records for Abundant Acres Care and Rehab
A list of the most recent deficiencies for Abundant Acres Care and Rehab. 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 Abundant Acres Care and Rehab. 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 hallway or ground-level exits in all residents' rooms. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-06-26 | 2024-08-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-26 | 2024-08-09 | 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 | 2024-06-26 | 2024-08-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-06-26 | 2024-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-26 | 2024-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-26 | 2024-08-09 | N |
| Provide activities to meet all resident's needs. | Health | 2024-06-26 | 2024-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-26 | 2024-08-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-26 | 2024-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-26 | 2024-08-09 | 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 | 2024-06-26 | 2024-08-09 | 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 | 2024-06-26 | 2024-08-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-06-26 | 2024-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-26 | 2024-08-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-06-26 | 2024-08-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-26 | 2024-08-09 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-06-26 | 2024-08-09 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-04-29 | 2024-06-13 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-04-03 | 2024-06-13 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-05-14 | 2024-05-19 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-14 | 2024-05-19 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-05-14 | 2024-05-19 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-14 | 2024-05-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-04-29 | 2024-05-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-04-03 | 2024-05-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-18 | 2024-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | 2024-03-15 | 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 | 2024-01-18 | 2024-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-31 | 2023-06-20 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-19 | 2023-05-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-01 | 2023-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-03-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-19 | 2023-03-27 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-19 | 2023-03-27 | 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 | 2023-01-19 | 2023-03-27 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-19 | 2023-03-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-19 | 2023-03-01 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-01-19 | 2023-03-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-19 | 2023-02-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-19 | 2023-02-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-19 | 2023-02-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-19 | 2023-02-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-02-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-19 | 2023-02-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-19 | 2023-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-19 | 2023-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-19 | 2023-02-23 | 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 | 2023-01-19 | 2023-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-19 | 2023-02-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Meet other general requirements. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-19 | 2023-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-19 | 2023-02-23 | 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 | 2022-11-14 | 2022-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-14 | 2022-12-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-21 | 2022-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-03-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-13 | 2022-01-17 | Y |
| 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 | 2021-12-13 | 2022-01-17 | 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 | 2019-11-06 | 2020-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-06 | 2019-12-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-06 | 2019-12-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-06 | 2019-12-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-06 | 2019-12-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-06 | 2019-12-20 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-06 | 2019-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-06 | 2019-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-12-20 | 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 | 2019-11-06 | 2019-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-06 | 2019-12-20 | N |
| Post nurse staffing information every day. | Health | 2019-11-06 | 2019-12-20 | 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 | 2019-11-06 | 2019-12-20 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-06 | 2019-12-20 | 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 | 2019-11-06 | 2019-12-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-11-06 | 2019-12-20 | 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 | 2019-11-06 | 2019-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-11-06 | 2019-12-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-03 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-03 | Not Fixed | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-04-03 | Not Fixed | Y |
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