Deficiency Records for Complete Care at Kimberly Hall-South
Updated as of April 01, 2024
A list of the most recent deficiencies for Complete Care at Kimberly Hall-South. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-24 | 2022-12-02 | 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 | 2022-06-09 | 2022-07-19 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-16 | 2022-07-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-16 | 2022-07-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-16 | 2022-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-16 | 2022-07-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-23 | 2022-06-30 | 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 | 2022-05-23 | 2022-06-30 | 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 | 2022-05-23 | 2022-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-23 | 2022-06-30 | 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 | 2022-05-23 | 2022-06-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-05-23 | 2022-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-23 | 2022-06-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-23 | 2022-06-30 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-11 | 2021-09-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-24 | 2019-12-05 | 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 | 2019-10-24 | 2019-12-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-24 | 2019-12-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-24 | 2019-12-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-24 | 2019-12-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-24 | 2019-12-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-24 | 2019-12-05 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-24 | 2019-12-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-21 | 2019-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-11-08 | 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 | 2018-08-23 | 2018-10-04 | 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 | 2018-08-23 | 2018-10-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-08-23 | 2018-10-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-23 | 2018-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-23 | 2018-10-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-23 | 2018-10-04 | N |
| 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 | 2018-08-23 | 2018-10-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-23 | 2018-10-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-23 | 2018-10-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-08-23 | 2018-10-04 | 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 | 2018-08-23 | 2018-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-23 | 2018-10-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-08-23 | 2018-10-04 | N |
