A list of the most recent deficiencies for Casa De Paz Health Care 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? |
|---|---|---|---|---|
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-03-16 | 2023-04-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-16 | 2023-04-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-16 | 2023-04-09 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-16 | 2023-04-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-09 | 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 | 2023-03-16 | 2023-04-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-16 | 2023-04-09 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-03-16 | 2023-04-09 | 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 | 2023-03-16 | 2023-04-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-20 | 2023-04-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-20 | 2023-04-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-20 | 2023-04-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-20 | 2023-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-20 | 2023-03-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-20 | 2023-03-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-20 | 2023-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-20 | 2023-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-20 | 2023-03-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-20 | 2023-03-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-20 | 2023-03-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-20 | 2023-03-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-30 | 2021-12-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-10-21 | 2021-11-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-11-04 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-09-30 | 2021-10-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-30 | 2021-10-29 | 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 | 2021-09-30 | 2021-10-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-09-30 | 2021-10-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-30 | 2021-10-29 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-09-30 | 2021-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-10-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-30 | 2021-10-29 | 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 | 2021-09-30 | 2021-10-29 | Y |
| 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 | 2021-09-30 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-10-29 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-29 | 2021-10-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-29 | 2021-10-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-29 | 2021-10-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-30 | 2021-10-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Develop a communication plan. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish methods for sharing information. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-29 | 2021-10-14 | 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 | 2021-09-29 | 2021-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-29 | 2021-10-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-29 | 2021-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-29 | 2021-10-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-09-29 | 2021-10-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-09-29 | 2021-10-08 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-09-29 | 2021-10-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-10 | 2019-10-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-10 | 2019-10-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-09-10 | 2019-10-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-10 | 2019-10-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-10-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-10 | 2019-10-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-10 | 2019-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-10 | 2019-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-10 | 2019-10-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-10 | 2019-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-10 | 2019-10-10 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-10 | 2019-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-10 | 2019-09-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-10 | 2019-09-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-10 | 2019-09-24 | 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 | 2019-09-10 | 2019-09-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-10 | 2019-09-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-10 | 2019-09-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-09-10 | 2019-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-10 | 2019-09-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-09-10 | 2019-09-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-10 | 2019-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-10 | 2019-09-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-10 | 2019-09-10 | N |
