A list of the most recent deficiencies for Peace Healthcare at Lions 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? |
|---|---|---|---|---|
| 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 | 2023-03-22 | 2023-06-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-22 | 2023-06-22 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-03-22 | 2023-05-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-22 | 2023-05-23 | 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 | 2023-03-22 | 2023-05-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-22 | 2023-05-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-22 | 2023-05-23 | 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 | 2023-03-22 | 2023-05-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-22 | 2023-05-23 | 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 | 2023-03-22 | 2023-05-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-22 | 2023-05-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-22 | 2023-05-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-22 | 2023-05-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-22 | 2023-05-23 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-22 | 2023-05-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-22 | 2023-05-23 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-03-22 | 2023-05-23 | 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 | 2023-03-22 | 2023-05-23 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-03-22 | 2023-05-23 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-22 | 2023-05-23 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-03-22 | 2023-05-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-22 | 2023-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-22 | 2023-05-23 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-22 | 2023-05-23 | 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 | 2023-03-22 | 2023-05-23 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-22 | 2023-05-23 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-03-22 | 2023-05-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-22 | 2023-05-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-22 | 2023-05-23 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-22 | 2023-05-23 | Y |
| 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 | 2023-03-22 | 2023-05-23 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-22 | 2023-05-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-28 | 2023-05-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-13 | 2022-03-01 | 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 | 2022-01-13 | 2022-03-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-13 | 2022-03-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-13 | 2022-03-01 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-01-13 | 2022-03-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-13 | 2022-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-13 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-13 | 2022-03-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-13 | 2022-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-03-01 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-13 | 2022-03-01 | Y |
| Report COVID19 data to residents and families. | Health | 2022-01-13 | 2022-03-01 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-01-13 | 2022-03-01 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-01-13 | 2022-03-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-11-28 | 2019-02-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-11-28 | 2019-02-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-29 | 2019-02-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-29 | 2019-02-06 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-11-29 | 2019-02-06 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-29 | 2019-02-06 | 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 | 2018-11-29 | 2019-02-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-29 | 2019-02-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-29 | 2019-02-06 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-11-29 | 2019-02-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-29 | 2019-02-06 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-11-29 | 2019-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-29 | 2019-02-06 | 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 | 2018-11-29 | 2019-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2019-02-06 | 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 | 2018-11-29 | 2019-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2019-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-29 | 2019-02-06 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-11-29 | 2019-02-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-11-29 | 2019-02-06 | 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 | 2018-11-29 | 2019-02-06 | 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 | 2018-11-29 | 2019-02-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-29 | 2019-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-02-06 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-08-31 | 2017-10-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-08-31 | 2017-10-02 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-31 | 2017-10-02 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-08-31 | 2017-10-02 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-31 | 2017-10-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-09-11 | 2017-10-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-11 | 2017-10-02 | N |
