A list of the most recent deficiencies for Leeway, Inc. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-17 | 2022-04-21 | 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 | 2022-03-17 | 2022-04-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-17 | 2022-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-21 | 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 | 2022-03-17 | 2022-04-21 | 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 | 2022-03-17 | 2022-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-12 | 2022-02-12 | 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 | 2019-08-15 | 2019-09-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-15 | 2019-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-15 | 2019-09-25 | 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 | 2019-08-15 | 2019-09-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-15 | 2019-09-25 | 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 | 2019-08-15 | 2019-09-25 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-20 | 2018-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-25 | 2018-10-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-25 | 2018-10-19 | N |
