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Deficiency Records for Enchanted Rock Skilled Nursing and Rehabilitation
A list of the most recent deficiencies for Enchanted Rock Skilled Nursing and Rehabilitation. 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 Enchanted Rock Skilled Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-13 | 2024-02-15 | 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 | 2024-01-13 | 2024-02-15 | 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 | 2024-01-13 | 2024-02-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-13 | 2024-02-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-13 | 2024-02-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-13 | 2024-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-13 | 2024-02-15 | 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 | 2024-01-13 | 2024-02-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-13 | 2024-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-13 | 2024-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-13 | 2024-02-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-13 | 2024-02-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-13 | 2024-02-15 | 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 | 2024-01-13 | 2024-02-15 | 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 | 2024-01-13 | 2024-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-13 | 2024-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-13 | 2024-02-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-13 | 2024-02-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-10 | 2024-02-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-10 | 2024-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-10 | 2024-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-20 | 2023-01-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-20 | 2023-01-21 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-11-16 | 2022-12-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-16 | 2022-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-16 | 2022-12-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-16 | 2022-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-16 | 2022-12-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-16 | 2022-12-23 | 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 | 2022-11-18 | 2022-12-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-18 | 2022-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-18 | 2022-12-22 | 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 | 2022-11-18 | 2022-12-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-18 | 2022-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-18 | 2022-12-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-18 | 2022-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2022-12-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-18 | 2022-12-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-27 | 2021-11-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-22 | 2021-11-05 | 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 | 2021-09-22 | 2021-11-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-27 | 2021-10-28 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-22 | 2021-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-22 | 2021-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-22 | 2021-10-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-22 | 2021-10-12 | 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 | 2021-09-22 | 2021-10-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-09-22 | 2021-10-04 | 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 | 2021-09-22 | 2021-10-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-22 | 2021-10-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-22 | 2021-09-23 | N |
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