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Deficiency Records for Las Flores Convalescent Hospital
A list of the most recent deficiencies for Las Flores Convalescent Hospital. 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 Las Flores Convalescent Hospital. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-28 | 2024-09-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-01 | 2024-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-01 | 2024-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-29 | 2024-06-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-13 | 2024-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-08 | 2024-05-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-08 | 2024-04-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-08 | 2024-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-08 | 2024-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-08 | 2024-04-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-08 | 2024-04-01 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-03-08 | 2024-04-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-08 | 2024-04-01 | 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 | 2024-03-08 | 2024-04-01 | 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 | 2024-03-08 | 2024-04-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-03-08 | 2024-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-08 | 2024-04-01 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-08 | 2024-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-08 | 2024-04-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-03-08 | 2024-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-08 | 2024-04-01 | N |
| Ensure resident rooms meet each resident's needs. | Health | 2024-03-08 | 2024-04-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-13 | 2024-03-27 | 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 | 2024-03-13 | 2024-03-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-03-13 | 2024-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-13 | 2024-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-13 | 2024-03-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-09 | 2024-03-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-14 | 2024-02-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-06 | 2023-11-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-23 | 2023-11-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-21 | 2023-09-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-21 | 2023-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-21 | 2023-09-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-21 | 2023-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-21 | 2023-09-30 | 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 | 2023-08-09 | 2023-08-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-09 | 2023-08-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-09 | 2023-08-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-09 | 2023-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2022-12-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-19 | 2022-08-23 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-06-23 | 2022-07-01 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-04 | 2022-06-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-28 | 2022-04-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-28 | 2022-04-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-10 | 2022-03-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-10 | 2022-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-10 | 2022-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-04 | 2022-02-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-18 | 2022-01-05 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-11-18 | 2022-01-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-18 | 2022-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2022-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-18 | 2022-01-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-11-18 | 2022-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2022-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2022-01-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-18 | 2022-01-05 | 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 | 2021-11-18 | 2022-01-05 | 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 | 2021-11-18 | 2022-01-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-18 | 2022-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2022-01-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-18 | 2022-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2022-01-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-18 | 2022-01-05 | N |
| Keep all essential equipment working safely. | Health | 2021-11-18 | 2022-01-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-18 | 2021-12-10 | 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 | 2021-11-18 | 2021-12-10 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-11-08 | 2019-12-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-08 | 2019-12-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-08 | 2019-12-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-08 | 2019-12-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-08 | 2019-12-16 | 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 | 2019-11-08 | 2019-12-16 | 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 | 2019-11-08 | 2019-12-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-08 | 2019-12-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-08 | 2019-12-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-08 | 2019-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-08 | 2019-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-08 | 2019-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-08 | 2019-12-16 | 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 | 2019-11-08 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-08 | 2019-12-16 | 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 | 2019-11-08 | 2019-12-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-08 | 2019-12-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-08 | 2019-12-16 | 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 | 2019-11-08 | 2019-12-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-08 | 2019-12-16 | 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 | 2019-11-08 | 2019-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-08 | 2019-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-08 | 2019-12-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-11-08 | 2019-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-08 | 2019-12-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-08 | 2019-12-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-11-08 | 2019-12-16 | N |
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