A list of the most recent deficiencies for Sixteen Acres Healthcare 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-04 | 2023-07-07 | 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 | 2023-05-04 | 2023-07-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-04 | 2023-07-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-04 | 2023-07-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-05-04 | 2023-07-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-04 | 2023-07-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-04 | 2023-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-07-07 | 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 | 2023-05-04 | 2023-07-07 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-04 | 2023-07-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-04 | 2023-07-07 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-04 | 2023-07-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-04 | 2023-07-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-04 | 2023-07-07 | N |
| Have policies on smoking. | Health | 2023-05-04 | 2023-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-09 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-26 | 2022-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-07 | 2022-09-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-07 | 2022-09-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-07 | 2022-09-16 | 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 | 2022-07-20 | 2022-08-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-20 | 2022-07-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-24 | 2022-07-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-19 | 2022-03-25 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-01-19 | 2022-03-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-19 | 2022-03-25 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-19 | 2022-03-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-19 | 2022-03-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-19 | 2022-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-19 | 2022-03-25 | 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 | 2022-01-19 | 2022-03-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-19 | 2022-03-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-19 | 2022-03-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-19 | 2022-03-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-19 | 2022-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-19 | 2022-03-25 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-01-19 | 2022-03-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-19 | 2022-03-25 | 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 | 2022-01-19 | 2022-03-25 | 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 | 2022-01-19 | 2022-03-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-19 | 2022-03-25 | 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 | 2022-01-19 | 2022-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-19 | 2022-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-19 | 2022-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-19 | 2022-03-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-19 | 2022-03-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-07 | 2022-03-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-07 | 2022-03-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-07 | 2022-03-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-07 | 2022-03-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-07 | 2022-03-25 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-02 | 2022-03-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-02 | 2022-03-19 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-02-02 | 2022-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-02 | 2022-03-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-21 | 2021-06-24 | Y |
