A list of the most recent deficiencies for Pelican Ridge Post Acute. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-04 | 2023-11-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-23 | 2023-09-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-23 | 2023-09-22 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2023-03-28 | 2023-05-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-12 | 2022-08-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-07-12 | 2022-08-11 | 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 | 2022-07-12 | 2022-08-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-12 | 2022-08-11 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-07-12 | 2022-08-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-12 | 2022-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-12 | 2022-08-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-12 | 2022-08-11 | 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 | 2022-07-12 | 2022-08-11 | 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 | 2022-07-12 | 2022-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-12 | 2022-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-12 | 2022-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-12 | 2022-08-11 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-11 | 2022-08-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-07-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-28 | 2021-10-28 | Y |
| 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 | 2021-07-22 | 2021-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-10 | 2021-05-18 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-04-15 | 2019-06-30 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-04-15 | 2019-06-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-15 | 2019-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-15 | 2019-06-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-15 | 2019-06-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-15 | 2019-06-30 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-06 | 2019-06-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-15 | 2019-05-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-15 | 2019-05-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-15 | 2019-05-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-15 | 2019-05-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-15 | 2019-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-15 | 2019-05-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-04-15 | 2019-05-30 | 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 | 2019-04-15 | 2019-05-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-15 | 2019-05-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-15 | 2019-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-15 | 2019-05-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-15 | 2019-05-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Develop a communication plan. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-08-02 | 2018-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-03 | 2018-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-03 | 2018-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-03 | 2018-06-01 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-05-03 | 2018-06-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-03 | 2018-06-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-03 | 2018-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-03 | 2018-06-01 | N |
