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Deficiency Records for The Peaks Health and Rehabilitation
View the most recent health deficiencies and inspection results for The Peaks Health and Rehabilitation. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Peaks Health and Rehabilitation. Stay informed about quality of care issues.
| 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 | 2025-07-10 | 2025-09-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-01-29 | 2025-03-28 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-11-07 | 2024-12-13 | N |
| Respond appropriately to all alleged violations. | Health | 2024-11-07 | 2024-12-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-11-07 | 2024-12-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-11-07 | 2024-12-13 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-11-07 | 2024-12-13 | 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 | 2024-11-07 | 2024-12-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-11-07 | 2024-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-11-07 | 2024-12-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-11-07 | 2024-12-13 | 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 | 2024-11-07 | 2024-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-07 | 2024-12-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-11-07 | 2024-11-18 | N |
| 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 |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-22 | 2023-10-16 | N |
| Report COVID19 data to residents and families. | 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 |
| 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 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-11 | 2022-10-15 | N |
| Post nurse staffing information every day. | 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-11 | 2022-10-15 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | 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 | 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 |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 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 |
| 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 |
| 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 | N |