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Deficiency Records for Communities at Indian Haven
A list of the most recent deficiencies for Communities at Indian Haven. 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 Communities at Indian Haven. 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-21 | 2024-05-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-21 | 2024-05-03 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-03-21 | 2024-05-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-21 | 2024-05-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-21 | 2024-05-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-21 | 2024-05-03 | 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 | 2024-03-21 | 2024-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-21 | 2024-05-03 | 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 | 2024-03-21 | 2024-05-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-21 | 2024-05-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-21 | 2024-05-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-21 | 2024-05-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-21 | 2024-05-03 | 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 | 2024-03-21 | 2024-05-03 | N |
| Meet other general requirements. | Fire Safety | 2024-03-26 | 2024-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-26 | 2024-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-26 | 2024-04-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-26 | 2024-04-29 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-03-26 | 2024-04-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-26 | 2024-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-20 | 2023-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-20 | 2023-07-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-20 | 2023-07-20 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-18 | 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 | 2023-03-16 | 2023-04-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-04-18 | 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 | 2023-03-16 | 2023-04-18 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-03-16 | 2023-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-18 | N |
| Report COVID19 data to residents and families. | Health | 2023-03-16 | 2023-04-18 | 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 | 2023-03-16 | 2023-04-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Meet other general requirements. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-09 | 2022-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-09 | 2022-05-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-09 | 2022-05-18 | 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 | 2022-04-09 | 2022-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-09 | 2022-05-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-09 | 2022-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-09 | 2022-05-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-09 | 2022-05-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-09 | 2022-05-18 | Y |
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