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Deficiency Records for Embassy of East Mountain
A list of the most recent deficiencies for Embassy of East Mountain. 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 Embassy of East Mountain. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2024-04-30 | 2024-06-01 | 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 | 2024-04-30 | 2024-06-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-30 | 2024-06-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-30 | 2024-06-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-30 | 2024-06-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-30 | 2024-06-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-04-12 | 2024-05-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-12 | 2024-05-21 | 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 | 2024-04-12 | 2024-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-12 | 2024-05-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-12 | 2024-05-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-12 | 2024-05-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-04-12 | 2024-05-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-12 | 2024-05-21 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-04-12 | 2024-05-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-09 | 2024-02-20 | 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 | 2024-01-09 | 2024-02-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-09 | 2024-02-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-21 | 2023-07-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-21 | 2023-07-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-21 | 2023-07-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-17 | 2023-07-06 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-17 | 2023-07-06 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-09 | 2023-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-09 | 2023-07-06 | 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 | 2023-06-09 | 2023-07-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-09 | 2023-07-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-09 | 2023-07-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-09 | 2023-07-06 | 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 | 2023-06-09 | 2023-07-06 | 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 | 2023-06-09 | 2023-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-09 | 2023-07-06 | N |
| Provide appropriate foot care. | Health | 2023-02-14 | 2023-03-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-14 | 2023-03-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-13 | 2023-01-03 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-26 | 2022-09-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-26 | 2022-09-30 | N |
| Post nurse staffing information every day. | Health | 2022-08-26 | 2022-09-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-26 | 2022-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-26 | 2022-09-30 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-08-26 | 2022-09-30 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-09 | 2022-09-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-09 | 2022-09-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-09 | 2022-09-15 | 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 | 2022-02-16 | 2022-03-14 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-16 | 2022-03-14 | 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 | 2022-02-16 | 2022-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-16 | 2022-03-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-16 | 2022-03-14 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-05 | 2022-02-16 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-05 | 2022-02-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-27 | Not Fixed | Y |
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