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Deficiency Records for Lacey Post Acute and Rehabilitation
A list of the most recent deficiencies for Lacey Post Acute 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 Lacey Post Acute 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-12 | 2024-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-12 | 2024-04-29 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-12 | 2023-10-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-12 | 2023-10-17 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-07 | 2023-10-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-07 | 2023-10-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-07 | 2023-10-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-07 | 2023-10-09 | 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 | 2023-09-07 | 2023-10-09 | 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 | 2023-09-07 | 2023-10-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-13 | 2023-10-09 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-12 | 2023-10-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-12 | 2023-10-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-02 | 2022-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-02 | 2022-10-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-30 | 2022-09-19 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-05 | 2022-09-07 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-08-05 | 2022-09-07 | 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 | 2022-08-05 | 2022-09-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-05 | 2022-09-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-05 | 2022-09-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-05 | 2022-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-05 | 2022-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-05 | 2022-09-07 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-05 | 2022-09-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-08-05 | 2022-09-07 | 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 | 2022-08-05 | 2022-09-07 | 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 | 2022-08-05 | 2022-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-05 | 2022-09-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Establish methods for sharing information. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-02 | 2022-08-31 | 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 | 2022-08-02 | 2022-08-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-02 | 2022-08-31 | 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 | 2022-08-02 | 2022-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-02 | 2022-08-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-22 | 2021-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-09 | 2020-02-21 | 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 | 2019-12-09 | 2020-02-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-09 | 2020-02-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-09 | 2020-02-21 | 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 | 2019-12-09 | 2020-02-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-12-09 | 2020-02-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-09 | 2020-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-09 | 2020-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-09 | 2020-02-21 | 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 | 2019-12-09 | 2020-02-21 | N |
| Post nurse staffing information every day. | Health | 2019-12-09 | 2020-02-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-09 | 2020-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-09 | 2020-02-21 | N |
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