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Deficiency Records for The Enclave
A list of the most recent deficiencies for The Enclave. 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 The Enclave. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-28 | 2024-06-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-28 | 2024-06-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-28 | 2024-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-28 | 2024-06-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-06-28 | 2024-06-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-28 | 2024-06-29 | 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 | 2024-06-28 | 2024-06-29 | 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 | 2024-06-28 | 2024-06-29 | 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 | 2024-06-28 | 2024-06-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-06-28 | 2024-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-28 | 2024-06-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-06-28 | 2024-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-28 | 2024-06-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-28 | 2024-06-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-27 | 2024-06-29 | 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 | 2024-06-27 | 2024-06-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-27 | 2024-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-27 | 2024-06-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-27 | 2024-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-27 | 2024-06-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-27 | 2024-06-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-27 | 2024-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-07 | 2024-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-04 | 2024-06-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-04 | 2024-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-04 | 2024-05-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-04 | 2024-05-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-04 | 2024-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-04 | 2024-05-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-29 | 2024-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-29 | 2024-01-30 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-19 | 2023-04-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-19 | 2023-04-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-19 | 2023-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-19 | 2023-04-27 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-04-19 | 2023-04-27 | 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 | 2023-03-24 | 2023-04-21 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-19 | 2022-12-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-19 | 2022-12-20 | 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 | 2022-12-19 | 2022-12-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-19 | 2022-12-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-15 | 2022-11-16 | 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 | 2022-03-04 | 2022-03-05 | 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 | 2022-03-04 | 2022-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-03-05 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-04 | 2022-03-05 | 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 | 2022-01-07 | 2022-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-28 | 2022-01-19 | Y |
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