A list of the most recent deficiencies for Lenox 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-05-19 | 2023-05-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-19 | 2023-05-30 | 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 | 2023-04-13 | 2023-05-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-13 | 2023-05-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-13 | 2023-05-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-13 | 2023-05-08 | 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 | 2023-04-13 | 2023-05-08 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-13 | 2023-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-13 | 2023-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-13 | 2023-05-08 | 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 | 2023-04-13 | 2023-05-08 | 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 | 2023-04-13 | 2023-05-08 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-04-13 | 2023-05-08 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-04-13 | 2023-05-08 | 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 | 2023-04-13 | 2023-05-08 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-04-13 | 2023-05-08 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-04-13 | 2023-05-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-13 | 2023-05-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-13 | 2023-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-05-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-04-13 | 2023-05-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-13 | 2023-05-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-13 | 2023-05-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-13 | 2023-05-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-30 | 2023-04-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-04 | 2022-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-04 | 2022-10-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-04 | 2022-10-20 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-10-04 | 2022-10-20 | Y |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-12-08 | 2021-12-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-08 | 2021-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-08 | 2021-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-02 | 2021-12-15 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-12-02 | 2021-12-15 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-08 | 2021-12-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-08 | 2021-12-10 | 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 | 2021-12-08 | 2021-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-08 | 2021-12-09 | N |
| Have an externally vented heating system. | Fire Safety | 2021-12-08 | 2021-12-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-08 | 2021-12-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-23 | 2019-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-23 | 2019-10-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-28 | 2019-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-28 | 2019-09-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-28 | 2019-09-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-28 | 2019-08-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-28 | 2019-08-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-28 | 2019-08-28 | 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 | 2019-08-28 | 2019-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-28 | 2019-08-28 | N |
