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The Village At Northrise - Desert Willow I

Inspection Results


Nursing Homes New Mexico Las Cruces The Village At Northrise - Desert Willow I

The Village At Northrise - Desert Willow I has been cited for a total of 101 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for The Village At Northrise - Desert Willow I.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 74 nursing homes in New Mexico with a total of 5,691 deficiencies resulting in an average of 76.91 deficiencies per nursing home.



The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies


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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-11-06
Corrected:
2023-12-21

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-14

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Make sure that a working call system is available in each resident's bathroom and bathing area.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-11-06
Corrected:
2023-12-21

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2023-01-12
Corrected:
2023-03-24

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Plan the resident's discharge to meet the resident's goals and needs.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Report COVID19 data to residents and families.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Plan the resident's discharge to meet the resident's goals and needs.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Implement a program that monitors antibiotic use.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Report COVID19 data to residents and families.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Category:
Quality of Life and Care Deficiencies
Scope:
F
From Complaint:
Y
Standard:
Y
Survey Date:
2022-02-21
Corrected:
2022-04-05

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2021-10-22
Corrected:
2021-11-17

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2021-10-22
Corrected:
2021-11-17

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-09

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-02-24

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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-02-24

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.
Category:
Pharmacy Service Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-09

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-05

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-02-12
Corrected:
2021-03-08

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
N
Survey Date:
2021-02-12
Corrected:
2021-03-08



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