A list of the most recent deficiencies for Menifee Lakes 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 | 2024-02-14 | 2024-02-22 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-27 | 2023-12-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-25 | 2023-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-18 | 2023-10-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-17 | 2023-10-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-27 | 2023-10-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-08-30 | Y |
| 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 | 2023-05-18 | 2023-06-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-18 | 2023-06-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-18 | 2023-06-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-18 | 2023-06-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-18 | 2023-06-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-06-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-18 | 2023-06-18 | 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 | 2023-05-18 | 2023-06-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-05-18 | 2023-06-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-18 | 2023-06-18 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-25 | 2023-06-09 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-05-22 | 2023-06-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-22 | 2023-06-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-22 | 2023-06-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-22 | 2023-06-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-15 | 2023-05-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-09 | 2023-05-19 | 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 | 2023-04-05 | 2023-05-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-05 | 2023-05-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-22 | 2023-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-12 | 2022-09-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-12 | 2022-09-23 | 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 | 2022-08-26 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-14 | 2022-07-14 | Y |
| 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 | 2022-01-06 | 2022-02-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-06 | 2022-02-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-12-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-14 | 2021-10-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-22 | 2021-05-25 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-01 | 2019-11-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-01 | 2019-11-19 | 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 | 2019-09-19 | 2019-10-15 | 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 | 2019-09-19 | 2019-10-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-19 | 2019-10-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-19 | 2019-10-15 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-19 | 2019-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-19 | 2019-10-15 | 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 | 2019-09-19 | 2019-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-19 | 2019-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-19 | 2019-10-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Develop a communication plan. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-12-20 | 2019-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-20 | 2019-01-08 | 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 | 2018-10-19 | 2018-11-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-19 | 2018-11-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-19 | 2018-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-19 | 2018-11-26 | 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 | 2018-10-19 | 2018-11-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-19 | 2018-11-26 | 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 | 2018-10-19 | 2018-11-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-10-19 | 2018-11-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-10-19 | 2018-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-19 | 2018-11-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-19 | 2018-11-26 | N |
