A list of the most recent deficiencies for Crown Point Christian Village. 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? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-10-26 | 2023-11-02 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-17 | 2023-06-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-24 | 2023-05-26 | 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 | 2023-04-24 | 2023-05-26 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-24 | 2023-05-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-24 | 2023-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-24 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-24 | 2023-05-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-24 | 2023-05-26 | 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 | 2023-04-24 | 2023-05-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-04-24 | 2023-05-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-24 | 2023-05-26 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-24 | 2023-05-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-24 | 2023-05-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-19 | 2023-01-20 | Y |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2022-04-12 | 2022-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-12 | 2022-05-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-12 | 2022-04-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-12 | 2022-04-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-12 | 2022-04-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-12 | 2022-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-21 | 2022-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-21 | 2022-04-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-04-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-21 | 2022-04-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-21 | 2022-04-08 | 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 | 2022-03-21 | 2022-04-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-21 | 2022-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-16 | 2021-12-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-27 | 2021-06-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-27 | 2021-06-22 | 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 | 2021-05-27 | 2021-06-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-27 | 2021-06-22 | Y |
| 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 | 2021-05-27 | 2021-06-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-10 | 2020-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-10 | 2020-03-10 | 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 | 2019-11-25 | 2020-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-25 | 2020-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-25 | 2020-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-25 | 2020-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-25 | 2020-01-23 | 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 | 2019-11-25 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-25 | 2020-01-23 | N |
