Deficiency Records for Advena Living of Cherryvale
Updated as of April 01, 2021
This is not the most recent data for Advena Living of Cherryvale. For the most recent information, click here.
A list of the most recent deficiencies for Advena Living of Cherryvale. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-01-04 | 2021-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-11-05 | 2020-12-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-11-05 | 2020-12-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-14 | 2020-11-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-14 | 2020-11-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-14 | 2020-11-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-14 | 2020-11-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-14 | 2020-11-27 | 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 | 2020-10-14 | 2020-11-27 | 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 | 2020-08-05 | 2020-09-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-08-05 | 2020-09-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-01 | 2020-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-07-20 | 2020-08-07 | Y |
| Provide activities to meet all resident's needs. | Health | 2019-08-14 | 2019-11-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-14 | 2019-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-14 | 2019-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-14 | 2019-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-14 | 2019-11-12 | 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 | 2019-08-14 | 2019-11-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-14 | 2019-11-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-14 | 2019-09-25 | 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 | 2019-08-14 | 2019-09-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-14 | 2019-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-14 | 2019-09-25 | 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 | 2019-08-14 | 2019-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-14 | 2019-09-25 | 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 | 2019-08-14 | 2019-09-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-14 | 2019-09-25 | N |
| Post nurse staffing information every day. | Health | 2019-08-14 | 2019-09-25 | 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 | 2019-08-14 | 2019-09-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-14 | 2019-09-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-14 | 2019-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-14 | 2019-09-25 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Establish methods for sharing information. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-20 | 2019-09-19 | 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 | 2019-08-20 | 2019-09-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-20 | 2019-09-19 | 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 | 2019-08-20 | 2019-09-19 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-20 | 2019-09-19 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-08-20 | 2019-08-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-20 | 2019-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-20 | 2019-08-20 | N |
| 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 | 2019-01-30 | 2019-02-15 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-10-31 | 2018-11-30 | 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 | 2018-10-31 | 2018-11-30 | 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 | 2018-10-31 | 2018-11-30 | 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 | 2018-10-31 | 2018-11-30 | 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 | 2018-10-31 | 2018-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-31 | 2018-11-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-31 | 2018-11-30 | 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 | 2018-10-31 | 2018-11-30 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-31 | 2018-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-31 | 2018-11-30 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-31 | 2018-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-10-31 | 2018-11-30 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-09-26 | 2018-10-26 | 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 | 2018-09-26 | 2018-10-26 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-09-26 | 2018-10-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-09-26 | 2018-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-04 | 2018-04-26 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-18 | 2017-10-27 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-18 | 2017-10-27 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-18 | 2017-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-18 | 2017-10-27 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-07-18 | 2017-10-27 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-07-18 | 2017-10-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-18 | 2017-10-27 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-07-18 | 2017-09-12 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2017-07-18 | 2017-09-12 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-18 | 2017-09-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-18 | 2017-09-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-18 | 2017-09-12 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-07-18 | 2017-09-12 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-18 | 2017-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-01-04 | 2017-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-04 | 2017-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-01-04 | 2017-01-31 | 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 | 2017-01-04 | 2017-01-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-01-04 | 2017-01-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-01-04 | 2017-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-04 | 2017-01-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-01-04 | 2017-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-01-04 | 2017-01-10 | N |
