Deficiency Records for Fleur Heights Center For Wellness and Rehab
Updated as of April 01, 2024
A list of the most recent deficiencies for Fleur Heights Center For Wellness and Rehab. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-29 | 2024-03-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-29 | 2024-03-12 | 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 | 2024-02-29 | 2024-03-12 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-01-25 | 2024-02-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-25 | 2024-02-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-25 | 2024-02-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-25 | 2024-02-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-25 | 2024-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-25 | 2024-02-16 | 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 | 2024-01-25 | 2024-02-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-25 | 2024-02-16 | 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 | 2023-12-21 | 2024-02-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-02 | 2024-02-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-02 | 2024-02-16 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-11-02 | 2024-02-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-02 | 2024-02-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-02 | 2024-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2024-02-16 | 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 | 2023-11-02 | 2024-02-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-21 | 2024-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-02 | 2023-12-04 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-11-02 | 2023-12-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-02 | 2023-12-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-02 | 2023-12-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-02 | 2023-12-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-02 | 2023-12-04 | N |
| Post nurse staffing information every day. | Health | 2023-11-02 | 2023-12-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-02 | 2023-12-04 | 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 | 2023-11-02 | 2023-12-04 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-11-02 | 2023-12-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-02 | 2023-12-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-02 | 2023-12-04 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-11-02 | 2023-12-04 | 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 | 2023-11-02 | 2023-12-04 | Y |
| 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 | 2023-11-02 | 2023-12-04 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-02 | 2023-12-04 | 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 | 2023-11-02 | 2023-12-04 | Y |
| 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 | 2023-11-02 | 2023-12-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-02 | 2023-12-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-04 | Y |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-10-31 | 2023-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-31 | 2023-11-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-31 | 2023-11-01 | N |
| 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 | 2023-06-16 | 2023-07-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-16 | 2023-07-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-16 | 2023-07-13 | 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 | 2023-06-16 | 2023-07-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-01 | 2023-05-17 | 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 | 2023-05-01 | 2023-05-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-01 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-01 | 2023-04-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-15 | 2023-03-16 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-02-15 | 2023-03-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-16 | 2023-01-17 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-12-16 | 2023-01-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-17 | 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 | 2022-12-16 | 2023-01-17 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-06-06 | 2022-07-05 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-06-06 | 2022-07-05 | 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 | 2022-06-06 | 2022-07-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-06 | 2022-07-05 | 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 | 2022-06-06 | 2022-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-06 | 2022-07-05 | 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 | 2022-06-06 | 2022-07-05 | N |
| Post nurse staffing information every day. | Health | 2022-06-06 | 2022-07-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-06 | 2022-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-06 | 2022-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-06 | 2022-07-05 | 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 | 2022-06-06 | 2022-07-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-06 | 2022-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-06 | 2022-07-05 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-02 | 2022-06-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-06-02 | 2022-06-14 | 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 | 2022-06-02 | 2022-06-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-02 | 2022-06-13 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-06-02 | 2022-06-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-02 | 2022-06-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-02 | 2022-06-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-02 | 2022-06-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-07 | 2022-01-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-07 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-07 | 2022-01-06 | Y |
| Keep all essential equipment working safely. | Health | 2021-12-07 | 2022-01-06 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-19 | 2021-05-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-19 | 2021-05-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-19 | 2021-05-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-19 | 2021-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-09 | 2021-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-09 | 2021-03-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-09 | 2021-03-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-09 | 2021-03-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-03-09 | 2021-03-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-10 | 2021-03-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-10 | 2021-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-03-10 | 2021-03-12 | N |
