A list of the most recent deficiencies for Leisure Homestead at Stafford. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-09-21 | 2023-10-21 | 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 | 2023-09-21 | 2023-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-10-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-21 | 2023-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-21 | 2023-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-09 | 2023-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-09 | 2023-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-09 | 2023-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-09 | 2023-10-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-15 | 2022-08-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-15 | 2022-08-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-15 | 2022-08-15 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-15 | 2022-08-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-08 | 2022-01-22 | 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 | 2021-12-08 | 2022-01-22 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-08 | 2022-01-22 | Y |
| 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 | 2021-12-08 | 2022-01-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-08 | 2022-01-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-08 | 2022-01-22 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-05 | 2022-01-13 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-30 | 2021-09-02 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-07-30 | 2021-09-02 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-07-30 | 2021-09-02 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-07-30 | 2021-09-02 | 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 | 2021-07-30 | 2021-09-02 | Y |
| 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 | 2020-02-18 | 2020-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-18 | 2020-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
