Deficiency Records for The Waters of Clifty Falls
Updated as of November 01, 2022
This is not the most recent data for The Waters of Clifty Falls. For the most recent information, click here.
A list of the most recent deficiencies for The Waters of Clifty Falls. 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Develop a communication plan. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Establish emergency prep training and testing. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-16 | 2022-07-15 | 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 | 2022-06-16 | 2022-07-15 | N |
Install proper backup exit lighting. | Fire Safety | 2022-06-16 | 2022-07-15 | 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 | 2022-06-16 | 2022-07-15 | N |
Provide properly protected cooking facilities. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-16 | 2022-07-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-06-20 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-16 | 2022-06-15 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-16 | 2022-06-15 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-16 | 2022-06-15 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-16 | 2022-06-15 | N |
Provide and implement an infection prevention and control program. | Health | 2022-05-16 | 2022-06-15 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 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 | 2021-12-16 | 2022-01-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-15 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-09 | 2021-09-16 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-18 | 2021-09-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-09-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-01 | 2021-04-26 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-01-14 | 2021-02-12 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-09-24 | 2020-10-23 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-09-24 | 2020-10-23 | 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 | 2020-02-24 | 2020-03-25 | N |
Meet other general requirements that are deficient. | Fire Safety | 2020-02-24 | 2020-03-25 | 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 | 2020-02-24 | 2020-03-25 | N |
Construct fire resistant interior walls. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-24 | 2020-03-25 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-09 | 2020-02-08 | N |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-09 | 2020-02-08 | N |
Ensure each resident receives an accurate assessment. | Health | 2020-01-09 | 2020-02-08 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-08 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-09 | 2020-02-08 | 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 | 2020-01-09 | 2020-02-08 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-08 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-01-09 | 2020-02-08 | 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 | 2020-01-09 | 2020-02-08 | 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 | 2020-01-09 | 2020-02-08 | N |
Ensure that residents are free from significant medication errors. | Health | 2020-01-09 | 2020-02-08 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-09 | 2020-02-08 | N |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-11-15 | 2019-11-26 | Y |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-16 | 2019-03-06 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-18 | 2019-01-17 | 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 | 2018-12-18 | 2019-01-17 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-18 | 2019-01-17 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-18 | 2019-01-17 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-18 | 2019-01-17 | 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 | 2018-12-18 | 2019-01-17 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-18 | 2019-01-17 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-18 | 2019-01-17 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-18 | 2019-01-17 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-18 | 2019-01-17 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-18 | 2019-01-17 | 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 | 2018-12-18 | 2019-01-17 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-12-18 | 2019-01-17 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-18 | 2019-01-17 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-12-18 | 2019-01-17 | N |
Provide and implement an infection prevention and control program. | Health | 2018-12-18 | 2019-01-17 | N |
Implement a program that monitors antibiotic use. | Health | 2018-12-18 | 2019-01-17 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-12-18 | 2019-01-17 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2019-01-16 | 2019-01-16 | N |
Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-01-16 | 2019-01-16 | 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 | 2019-01-16 | 2019-01-16 | N |
Have exits that are accessible at all times. | Fire Safety | 2019-01-16 | 2019-01-16 | 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 | 2019-01-16 | 2019-01-16 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-01-16 | 2019-01-16 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-16 | 2019-01-16 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-16 | 2019-01-16 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-16 | 2019-01-16 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-16 | 2019-01-16 | N |
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-01-16 | 2019-01-16 | N |