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Deficiency Records for Kirtland Rehabilitation and Care
A list of the most recent deficiencies for Kirtland Rehabilitation and Care. 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 Kirtland Rehabilitation and Care. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-29 | 2024-08-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-29 | 2024-08-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-29 | 2024-08-21 | Y |
| Ensure resident rooms meet each resident's needs. | Health | 2024-07-29 | 2024-08-21 | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2024-07-29 | 2024-08-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-29 | 2024-08-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-18 | 2024-08-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-05-02 | 2024-08-21 | 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 | 2024-05-02 | 2024-08-21 | 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 | 2024-05-02 | 2024-08-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-02 | 2024-08-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-02 | 2024-08-21 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-05-02 | 2024-08-21 | Y |
| Use approved construction type or materials. | Fire Safety | 2024-04-23 | 2024-08-21 | 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 | 2024-04-23 | 2024-08-21 | 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 | 2024-04-23 | 2024-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-08-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-23 | 2024-08-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-23 | 2024-08-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-23 | 2024-08-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-23 | 2024-08-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-18 | 2024-07-29 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-18 | 2024-07-29 | 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 | 2024-06-18 | 2024-07-29 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-05-02 | 2024-07-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-02 | 2024-07-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-02 | 2024-07-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-05-02 | 2024-07-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-02 | 2024-07-29 | N |
| 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 | 2024-05-02 | 2024-07-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-02 | 2024-07-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-02 | 2024-07-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-02 | 2024-07-29 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-05-02 | 2024-07-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-02 | 2024-07-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-02 | 2024-07-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-02 | 2024-07-29 | Y |
| Keep all essential equipment working safely. | Health | 2024-05-02 | 2024-07-29 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2024-05-02 | 2024-07-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-23 | 2024-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-12-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-12-06 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-07-20 | 2023-12-06 | 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 | 2023-07-20 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-28 | 2023-11-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-28 | 2023-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-28 | 2023-11-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-28 | 2023-11-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-20 | 2023-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-11-15 | 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 | 2023-07-20 | 2023-11-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-20 | 2023-11-15 | Y |
| 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 | 2023-07-20 | 2023-11-15 | 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 | 2023-07-20 | 2023-11-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-02 | 2023-09-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-02 | 2023-09-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-27 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-27 | 2023-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-27 | 2023-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-21 | 2023-02-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-29 | 2023-01-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-29 | 2023-01-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-21 | 2021-11-19 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-10-21 | 2021-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2021-11-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-10-21 | 2021-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-21 | 2021-11-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
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