Deficiency Records for Peace Healthcare at Lions Center
Updated as of June 01, 2019
This is not the most recent data for Peace Healthcare at Lions Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 ne | 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 |
| 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 |
| 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 |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-03-02 | 2017-03-31 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-03-02 | 2017-03-31 | Y |
| Exits that are accessible at all times. | Fire Safety | 2016-09-01 | 2016-11-07 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-09-01 | 2016-11-07 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-09-01 | 2016-11-07 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-08-25 | 2016-09-30 | N |
| Provide housekeeping and maintenance services. | Health | 2016-08-25 | 2016-09-30 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-08-25 | 2016-09-30 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-08-25 | 2016-09-30 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-08-25 | 2016-09-30 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-08-25 | 2016-09-30 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2016-08-25 | 2016-09-30 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-07-13 | 2016-08-15 | Y |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2016-07-13 | 2016-08-15 | Y |
