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Deficiency Records for Lily Springs Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Lily Springs Rehabilitation and Healthcare Center. 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 Lily Springs Rehabilitation and Healthcare Center. 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 special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-07-24 | 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 | 2024-07-19 | 2024-08-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-13 | 2024-07-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-13 | 2024-07-14 | 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 | 2024-06-13 | 2024-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-19 | 2024-04-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-04 | 2024-04-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-04 | 2024-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-04 | 2024-04-05 | 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 | 2024-04-04 | 2024-04-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-31 | 2024-03-08 | 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 | 2024-01-31 | 2024-03-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-01-31 | 2024-03-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-31 | 2024-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-31 | 2024-03-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-31 | 2024-03-08 | 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 | 2024-01-31 | 2024-03-08 | 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 | 2024-01-31 | 2024-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-31 | 2024-03-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-31 | 2024-03-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-31 | 2024-03-08 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-29 | 2023-08-16 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-13 | 2023-02-18 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-30 | 2022-12-27 | 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 | 2022-11-30 | 2022-12-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-30 | 2022-12-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-30 | 2022-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-30 | 2022-12-27 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-30 | 2022-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-30 | 2022-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-30 | 2022-12-27 | 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 | 2022-11-30 | 2022-12-27 | 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 | 2022-02-25 | 2022-02-26 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-09-30 | 2021-10-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-30 | 2021-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-30 | 2021-10-22 | 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 | 2021-09-30 | 2021-10-22 | 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 | 2021-09-30 | 2021-10-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-09-30 | 2021-10-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-30 | 2021-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-10-22 | N |
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