Deficiency Records for Community Memorial Continuing Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Community Memorial Continuing 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? |
|---|---|---|---|---|
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-11-30 | 2023-12-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-16 | 2023-09-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-16 | 2023-09-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-03 | 2023-08-15 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-04-25 | 2023-05-25 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-04-25 | 2023-05-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-04-25 | 2023-05-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-05-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-25 | 2023-05-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-21 | 2023-05-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-21 | 2023-05-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-04-21 | 2023-05-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-21 | 2023-05-21 | 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 | 2023-04-21 | 2023-05-21 | 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 | 2023-04-21 | 2023-05-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-21 | 2023-05-21 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-01-27 | 2023-01-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-22 | 2022-12-02 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-07-27 | 2022-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-24 | 2022-06-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-03 | 2021-12-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-12-12 | 2019-12-26 | 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 | 2019-12-12 | 2019-12-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-12 | 2019-12-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-12 | 2019-12-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-12-12 | 2019-12-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-12 | 2019-12-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-12 | 2019-12-26 | 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 | 2019-10-31 | 2019-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-30 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-31 | 2019-11-30 | 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 | 2019-10-31 | 2019-11-30 | 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 | 2019-10-31 | 2019-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-31 | 2019-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-31 | 2019-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-29 | 2019-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-29 | 2019-02-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-01-29 | 2019-02-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-29 | 2019-02-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-08 | 2018-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-08 | 2018-12-14 | 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 | 2018-11-08 | 2018-12-14 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-11-08 | 2018-12-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-11-08 | 2018-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-08 | 2018-12-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-11-08 | 2018-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-08 | 2018-12-14 | N |
