A list of the most recent deficiencies for Double Tree Post Acute Care 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-21 | 2023-09-12 | 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 | 2023-08-21 | 2023-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-21 | 2023-09-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-17 | 2023-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-17 | 2023-09-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-17 | 2023-09-08 | 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 | 2023-08-17 | 2023-09-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-17 | 2023-09-08 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-08-17 | 2023-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-08 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-08-17 | 2023-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-08 | N |
| Keep all essential equipment working safely. | Health | 2023-08-17 | 2023-09-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-17 | 2023-09-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-17 | 2023-09-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-18 | 2023-08-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-07-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-06 | 2023-04-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-06 | 2023-04-27 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-21 | 2023-04-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-28 | 2023-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-23 | 2023-02-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-13 | 2022-11-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-12 | 2022-10-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-12 | 2022-10-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-24 | 2022-04-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-20 | 2021-12-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-20 | 2021-12-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-04 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-06-23 | 2021-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-27 | 2021-09-14 | 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 | 2021-04-27 | 2021-09-14 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-04 | 2021-09-14 | 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 | 2021-08-04 | 2021-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-04 | 2021-09-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-22 | 2021-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-22 | 2021-08-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-22 | 2021-08-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-22 | 2021-08-31 | 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 | 2021-07-22 | 2021-08-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-22 | 2021-08-31 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-07-22 | 2021-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-22 | 2021-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-22 | 2021-08-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-04 | 2021-08-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-04 | 2021-08-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-24 | 2021-06-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-08 | 2021-03-18 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-08-12 | 2020-08-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-08-12 | 2020-08-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-08-12 | 2020-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-12 | 2020-08-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-08-12 | 2020-08-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-12 | 2020-08-14 | 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 | 2020-03-12 | 2020-08-14 | 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 | 2020-03-12 | 2020-08-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-12 | 2020-08-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-12 | 2020-08-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-12 | 2020-08-14 | 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 | 2020-03-12 | 2020-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-12 | 2020-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-12 | 2020-08-14 | N |
