Deficiency Records for Santa Ana Healthcare and Wellness Centre, LP
Updated as of October 01, 2021
This is not the most recent data for Santa Ana Healthcare and Wellness Centre, LP. For the most recent information, click here.
A list of the most recent deficiencies for Santa Ana Healthcare and Wellness Centre, LP. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-10 | 2021-06-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-29 | 2021-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-29 | 2021-05-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-29 | 2021-05-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-14 | 2021-04-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-29 | 2020-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-09 | 2020-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-07-06 | 2020-07-17 | Y |
| 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. | Health | 2020-06-09 | 2020-06-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-03-11 | 2020-03-16 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-20 | 2020-03-04 | 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 | 2019-10-14 | 2019-10-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-14 | 2019-10-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-21 | 2019-09-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-21 | 2019-09-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-24 | 2019-08-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-24 | 2019-08-07 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-11 | 2019-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-11 | 2019-05-13 | 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 | 2019-03-11 | 2019-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-11 | 2019-04-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-11 | 2019-04-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-03-11 | 2019-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-11 | 2019-04-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-11 | 2019-04-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-03-11 | 2019-04-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-03-11 | 2019-04-26 | N |
| Dispose of garbage and refuse properly. | Health | 2019-03-11 | 2019-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-11 | 2019-04-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-11 | 2019-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-11 | 2019-04-26 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-03-15 | 2019-04-15 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-03-15 | 2019-04-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-12-07 | 2019-01-07 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-26 | 2018-12-26 | Y |
| 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 | 2018-11-26 | 2018-12-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-26 | 2018-12-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-28 | 2018-04-28 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-03-28 | 2018-04-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-03-28 | 2018-04-28 | N |
| 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. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-03-28 | 2018-04-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-28 | 2018-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-28 | 2018-04-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-28 | 2018-04-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Dispose of garbage and refuse properly. | Health | 2018-03-28 | 2018-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-28 | 2018-04-28 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-04-10 | 2017-05-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-04-10 | 2017-05-10 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-04-10 | 2017-05-10 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-04-10 | 2017-05-10 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-10 | 2017-05-10 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-10 | 2017-05-10 | N |
| Provide housekeeping and maintenance services. | Health | 2017-04-10 | 2017-05-10 | N |
| Maintain comfortable sound levels. | Health | 2017-04-10 | 2017-05-10 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-10 | 2017-05-10 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-10 | 2017-05-10 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2017-04-10 | 2017-05-10 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-10 | 2017-05-10 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-04-10 | 2017-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-10 | 2017-05-10 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-04-10 | 2017-05-10 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-10 | 2017-05-10 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-10 | 2017-05-10 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-04-10 | 2017-05-10 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2017-04-10 | 2017-05-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-10 | 2017-05-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-10 | 2017-05-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-04-10 | 2017-05-10 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-04-10 | 2017-05-10 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-10 | 2017-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-04-18 | 2017-05-08 | N |
