A list of the most recent deficiencies for Las Colinas 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-11-21 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-09-08 | 2023-09-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-30 | 2023-09-06 | 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 | 2023-08-30 | 2023-09-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-01 | 2023-06-20 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-05-22 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-04-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-09 | 2023-02-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-08 | 2023-02-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-03 | 2023-02-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-07 | 2023-02-14 | 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 | 2023-02-07 | 2023-02-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-07 | 2023-02-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-08 | 2022-12-30 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-03 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-20 | 2022-11-02 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-18 | 2022-04-08 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-03-18 | 2022-04-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-18 | 2022-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-18 | 2022-04-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-18 | 2022-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-04-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-18 | 2022-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-08-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-29 | 2021-05-13 | Y |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-06-26 | 2019-08-13 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-26 | 2019-08-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-26 | 2019-08-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-26 | 2019-08-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-23 | 2019-06-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-23 | 2019-06-22 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-05-23 | 2019-06-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-05-23 | 2019-06-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-23 | 2019-06-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-23 | 2019-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-23 | 2019-06-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-05-23 | 2019-06-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-23 | 2019-06-22 | N |
| Develop a communication plan. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-06-28 | 2018-07-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-23 | 2018-05-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-23 | 2018-05-31 | 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 | 2018-04-23 | 2018-05-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-23 | 2018-05-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-04-23 | 2018-05-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-23 | 2018-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-23 | 2018-05-31 | 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 | 2018-04-23 | 2018-05-31 | N |
| Provide activities to meet all resident's needs. | Health | 2018-04-23 | 2018-05-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-04-23 | 2018-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-23 | 2018-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-23 | 2018-05-31 | 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 | 2018-04-23 | 2018-05-31 | N |
| Provide or obtain dental services for each resident. | Health | 2018-04-23 | 2018-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-23 | 2018-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-23 | 2018-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-23 | 2018-05-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-04-23 | 2018-05-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-04-23 | 2018-05-31 | N |
