Deficiency Records for Complete Care at Kimberly Hall North
Updated as of March 01, 2024
A list of the most recent deficiencies for Complete Care at Kimberly Hall North. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-12 | 2022-12-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2022-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-12 | 2022-12-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-02 | 2022-07-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-26 | 2022-07-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-26 | 2022-07-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-26 | 2022-07-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-26 | 2022-07-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-05-26 | 2022-07-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-26 | 2022-07-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-06-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-26 | 2022-06-12 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-10 | 2021-09-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-10 | 2021-09-06 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-08-10 | 2021-09-06 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-12-12 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-26 | 2019-11-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-26 | 2019-11-05 | 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 | 2019-09-26 | 2019-11-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-26 | 2019-11-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-26 | 2019-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-26 | 2019-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-11-05 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-26 | 2019-11-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-08-28 | 2018-11-13 | 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 | 2018-08-28 | 2018-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-28 | 2018-11-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-28 | 2018-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-28 | 2018-11-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-28 | 2018-11-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-28 | 2018-11-13 | 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 | 2018-08-30 | 2018-10-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-30 | 2018-10-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-30 | 2018-10-11 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-08-30 | 2018-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-30 | 2018-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-30 | 2018-10-11 | N |
