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Deficiency Records for Koester Pavilion
A list of the most recent deficiencies for Koester Pavilion. 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 Koester Pavilion. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-07-25 | 2024-08-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-07-25 | 2024-08-23 | 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 | 2024-07-25 | 2024-08-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-07-25 | 2024-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-25 | 2024-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-25 | 2024-08-23 | 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 | 2024-07-25 | 2024-08-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-07-25 | 2024-08-23 | 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 | 2024-07-25 | 2024-08-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-07-25 | 2024-08-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-25 | 2024-08-23 | 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 | 2024-07-25 | 2024-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-25 | 2024-08-23 | 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 | 2024-07-23 | 2024-08-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-23 | 2024-08-23 | 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 | 2024-07-23 | 2024-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-23 | 2024-08-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-03 | 2022-03-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-23 | 2021-12-13 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-11-23 | 2021-12-13 | 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 | 2021-11-23 | 2021-12-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-23 | 2021-12-13 | 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 | 2021-11-23 | 2021-12-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-23 | 2021-12-13 | 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 | 2021-11-23 | 2021-12-13 | 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 | 2021-11-23 | 2021-12-13 | 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 | 2021-11-23 | 2021-12-13 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-23 | 2021-12-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-23 | 2021-12-13 | 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 | 2021-11-22 | 2021-12-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-22 | 2021-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-22 | 2019-09-16 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-08-22 | 2019-09-16 | 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 | 2019-08-22 | 2019-09-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-22 | 2019-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-22 | 2019-09-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-22 | 2019-09-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-08-22 | 2019-09-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-22 | 2019-09-16 | 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 | 2019-08-21 | 2019-09-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-08-21 | 2019-09-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-21 | 2019-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-21 | 2019-09-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-21 | 2019-09-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-21 | 2019-09-16 | N |
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