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Deficiency Records for Kings Daughters Community Health and Rehab
A list of the most recent deficiencies for Kings Daughters Community Health and Rehab. 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 Kings Daughters Community Health and Rehab. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-17 | 2024-08-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-17 | 2024-07-15 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-04-17 | 2024-07-15 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-04-17 | 2024-07-15 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-04-17 | 2024-07-15 | Y |
| 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 | 2024-04-17 | 2024-07-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-17 | 2024-07-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-17 | 2024-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-17 | 2024-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-17 | 2024-07-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-17 | 2024-07-15 | 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 | 2024-04-17 | 2024-07-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-17 | 2024-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-17 | 2024-07-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-17 | 2024-07-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-17 | 2024-07-15 | Y |
| 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 | 2024-04-17 | 2024-07-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-17 | 2024-07-15 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-17 | 2024-07-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-04-17 | 2024-07-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-04-17 | 2024-07-15 | Y |
| 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 | 2024-04-17 | 2024-07-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-17 | 2024-07-15 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-04-17 | 2024-07-15 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-04-17 | 2024-07-15 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-04-17 | 2024-07-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-17 | 2024-07-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-04-17 | 2024-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-17 | 2024-07-15 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-04-17 | 2024-07-15 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-04-17 | 2024-07-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-02 | 2023-03-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-02 | 2023-03-08 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-08-04 | 2022-09-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-04 | 2022-09-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-04 | 2022-09-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-04 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-04 | 2022-09-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-09-07 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-08-04 | 2022-09-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-04 | 2022-09-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-15 | 2021-05-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-15 | 2021-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-15 | 2021-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-15 | 2021-05-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-15 | 2021-05-19 | 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 | 2021-04-15 | 2021-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-05-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-21 | 2021-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-21 | 2021-05-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-24 | 2019-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-24 | 2019-07-22 | 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 | 2019-06-24 | 2019-07-22 | 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 | 2019-06-24 | 2019-07-22 | 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 | 2019-06-24 | 2019-07-22 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-06-24 | 2019-07-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-24 | 2019-07-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-06-24 | 2019-07-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | Not Fixed | 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 | 2023-02-02 | Not Fixed | 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 | 2023-02-02 | Not Fixed | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-02-02 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | Not Fixed | N |
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