A list of the most recent deficiencies for Empress Care Center, LLC. 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? |
|---|---|---|---|---|
| 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 | 2022-09-02 | 2022-10-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-09-02 | 2022-10-02 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-02 | 2022-10-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-02 | 2022-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-10-02 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-02 | 2022-10-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-02 | 2022-10-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-09-07 | 2022-09-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-01 | 2021-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-11 | 2021-05-19 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-10-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-25 | 2019-10-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-25 | 2019-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-25 | 2019-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-25 | 2019-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-25 | 2019-10-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-25 | 2019-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-10-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-25 | 2019-10-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-29 | 2018-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-29 | 2018-12-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-28 | 2018-10-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-28 | 2018-10-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-28 | 2018-10-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-28 | 2018-10-18 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-28 | 2018-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-28 | 2018-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-28 | 2018-10-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-28 | 2018-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-28 | 2018-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-28 | 2018-10-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-09-28 | 2018-10-18 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-09-28 | 2018-10-18 | N |
