Deficiency Records for Almaden Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Almaden Health and Rehabilitation Center. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-09 | 2023-08-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-28 | 2023-06-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-28 | 2023-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-28 | 2023-06-02 | N |
| Provide appropriate foot care. | Health | 2023-04-28 | 2023-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-28 | 2023-06-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-28 | 2023-06-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-28 | 2023-06-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-28 | 2023-06-02 | 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 | 2023-04-28 | 2023-06-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-28 | 2023-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-28 | 2023-06-02 | 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 | 2023-04-28 | 2023-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-28 | 2023-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-06-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-28 | 2023-06-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-02 | 2023-05-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-04 | 2023-04-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-09 | 2023-03-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-20 | 2023-01-03 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-07-07 | 2022-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-07 | 2022-07-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-02 | 2022-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2021-12-31 | 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 | 2021-11-30 | 2021-12-14 | 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 | 2021-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-02 | 2021-10-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-02 | 2021-10-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-02 | 2021-10-02 | Y |
| Provide appropriate foot care. | Health | 2021-09-02 | 2021-10-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-09-30 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-08-27 | 2021-09-30 | Y |
| 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 | 2021-08-27 | 2021-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-24 | 2021-09-17 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-04 | 2021-06-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-05-07 | 2021-06-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-06-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-02 | 2021-03-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-02 | 2021-03-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-02 | 2021-03-26 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-02 | 2021-03-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-08 | 2021-03-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-20 | 2020-03-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-20 | 2020-03-20 | 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 | 2020-01-24 | 2020-02-12 | 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 | 2020-01-24 | 2020-02-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-24 | 2020-02-12 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-24 | 2020-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-24 | 2020-02-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-04-30 | 2019-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-15 | 2019-03-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-15 | 2019-03-18 | N |
| Provide appropriate foot care. | Health | 2019-02-15 | 2019-03-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-15 | 2019-03-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-15 | 2019-03-18 | 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 | 2019-02-15 | 2019-03-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-15 | 2019-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-15 | 2019-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-15 | 2019-03-18 | N |
