A list of the most recent deficiencies for Healthcare at College Park, 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? |
|---|---|---|---|---|
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-01-05 | 2023-02-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-05 | 2023-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-05 | 2023-02-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-05 | 2023-02-19 | 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 | 2023-01-05 | 2023-02-19 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-01-05 | 2023-02-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-05 | 2023-02-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-05 | 2023-02-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-05 | 2023-02-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-05 | 2022-11-19 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-10-05 | 2022-11-19 | Y |
| Keep all essential equipment working safely. | Health | 2022-10-05 | 2022-11-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-29 | 2022-06-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-29 | 2022-06-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-29 | 2022-06-15 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-03-29 | 2022-06-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-29 | 2022-06-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-29 | 2022-06-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-29 | 2022-06-15 | 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 | 2020-03-05 | 2020-04-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-03-05 | 2020-04-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-05 | 2020-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-04-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-03 | 2020-04-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-03 | 2020-04-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-03-03 | 2020-04-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-06-24 | 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 | 2019-05-17 | 2019-06-24 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-05-17 | 2019-06-24 | 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 | 2019-05-17 | 2019-06-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-17 | 2019-06-24 | 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 | 2019-05-17 | 2019-06-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-05-14 | 2019-06-24 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-05-14 | 2019-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-14 | 2019-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-14 | 2019-06-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-14 | 2019-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-14 | 2019-06-24 | N |
