A list of the most recent deficiencies for The Peaks Health 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 nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-09-22 | 2023-11-15 | Y |
| 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 | 2022-08-11 | 2022-10-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-11 | 2022-10-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-11 | 2022-10-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-11 | 2022-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-10-15 | N |
| Post nurse staffing information every day. | Health | 2022-08-11 | 2022-10-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-11 | 2022-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-10-15 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-11 | 2022-10-15 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-11 | 2022-10-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-11 | 2022-10-15 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-11 | 2022-10-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-11 | 2022-10-15 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-11 | 2022-10-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-11 | 2021-01-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-27 | 2020-04-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-27 | 2020-04-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-27 | 2020-04-24 | 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 | 2020-02-27 | 2020-04-24 | N |
