A list of the most recent deficiencies for Complete Care at Silver Lake LLC. 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2022-12-09 | 2023-01-23 | 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 | 2022-12-09 | 2023-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-23 | 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 | 2022-12-09 | 2023-01-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-09 | 2023-01-23 | 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 | 2022-12-09 | 2023-01-23 | 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 | 2022-12-09 | 2023-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-09 | 2023-01-23 | N |
| Keep all essential equipment working safely. | Health | 2022-12-09 | 2023-01-23 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-12-09 | 2023-01-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-29 | 2021-04-27 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-22 | 2019-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-22 | 2019-09-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-22 | 2019-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | 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 | 2019-08-22 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-22 | 2019-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-22 | 2019-09-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-22 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-30 | 2019-09-30 | 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 | 2019-08-30 | 2019-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-30 | 2019-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-30 | 2019-09-30 | 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 | 2018-10-18 | 2018-11-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-18 | 2018-11-19 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-18 | 2018-11-19 | 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 | 2018-10-18 | 2018-11-19 | 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 | 2018-10-18 | 2018-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-18 | 2018-11-19 | 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 | 2018-10-18 | 2018-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-18 | 2018-11-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-10-18 | 2018-11-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-18 | 2018-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-18 | 2018-11-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-19 | 2018-11-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-18 | 2018-05-30 | N |
