A list of the most recent deficiencies for Azria Health Park Place. 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 implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-21 | 2023-12-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-21 | 2023-12-21 | 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 | 2023-11-21 | 2023-12-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-21 | 2023-12-21 | 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 | 2023-11-21 | 2023-12-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-21 | 2023-12-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-21 | 2023-12-21 | N |
| Post nurse staffing information every day. | Health | 2023-11-21 | 2023-12-21 | 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 | 2023-11-21 | 2023-12-21 | 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 | 2023-11-21 | 2023-12-21 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-21 | 2023-12-21 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-11-21 | 2023-12-21 | 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 | 2023-11-21 | 2023-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-21 | 2023-12-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-21 | 2023-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2023-12-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-21 | 2023-12-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-21 | 2023-12-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-21 | 2023-12-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-21 | 2023-12-21 | 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 | 2023-11-21 | 2023-12-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-21 | 2023-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-21 | 2023-12-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-21 | 2023-12-21 | Y |
| 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 | 2023-11-21 | 2023-12-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-21 | 2023-12-21 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-11-21 | 2023-11-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-06 | 2023-07-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-06 | 2023-07-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-06 | 2023-07-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-06 | 2023-07-27 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-11-09 | 2023-01-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-09 | 2023-01-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-09 | 2023-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-09 | 2023-01-12 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-11-09 | 2023-01-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-09 | 2023-01-12 | 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 | 2022-11-09 | 2023-01-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-09 | 2023-01-12 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-11-09 | 2023-01-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-09 | 2023-01-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-09 | 2023-01-12 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-08 | 2022-11-22 | 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 | 2022-11-08 | 2022-11-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-08 | 2022-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-08 | 2022-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2022-10-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-28 | 2022-10-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2022-10-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-28 | 2022-10-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-17 | 2021-12-06 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-28 | 2021-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-28 | 2021-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-28 | 2021-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-28 | 2021-08-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-07-28 | 2021-08-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-28 | 2021-08-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-28 | 2021-08-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-28 | 2021-08-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-28 | 2021-08-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-08-20 | 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 | 2021-07-28 | 2021-08-20 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-07-28 | 2021-08-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-28 | 2021-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-28 | 2021-08-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-28 | 2021-08-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-28 | 2021-08-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-08-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-13 | Not Fixed | 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 | 2022-07-13 | Not Fixed | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-13 | Not Fixed | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-13 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-13 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-13 | Not Fixed | 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 | 2022-07-13 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-13 | Not Fixed | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-13 | Not Fixed | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-13 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-13 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | Not Fixed | Y |
| Keep all essential equipment working safely. | Health | 2022-07-13 | Not Fixed | Y |
