A list of the most recent deficiencies for Tierra Pines 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? |
|---|---|---|---|---|
| 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 | 2023-10-31 | 2023-11-17 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-06 | 2023-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2023-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-08 | 2023-01-07 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-12-08 | 2023-01-07 | 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 | 2022-12-08 | 2023-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2023-01-07 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-08 | 2023-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2023-01-07 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-08 | 2023-01-07 | Y |
| 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 | 2022-12-08 | 2023-01-07 | Y |
| 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 | 2022-12-08 | 2023-01-07 | Y |
| 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 | 2022-12-06 | 2023-01-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-06 | 2023-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-06 | 2023-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-06 | 2023-01-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-06 | 2023-01-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-04-09 | 2021-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-09 | 2021-05-09 | 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 | 2021-04-09 | 2021-05-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-07 | 2021-05-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-07 | 2021-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-11 | 2019-05-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-11 | 2019-05-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-11 | 2019-05-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-11 | 2019-05-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-11 | 2019-05-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-11 | 2019-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-11 | 2019-05-11 | 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 | 2019-04-11 | 2019-05-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-04-11 | 2019-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-11 | 2019-05-11 | N |
