Deficiency Records for Sixteen Acres Healthcare Center
Updated as of August 01, 2019
This is not the most recent data for Sixteen Acres Healthcare Center. For the most recent information, click here.
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 properly protected cooking facilities. | Fire Safety | 2018-02-20 | 2018-03-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-01-31 | 2018-03-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-31 | 2018-03-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-31 | 2018-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-01-31 | 2018-03-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-01-31 | 2018-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-01-31 | 2018-03-15 | 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 | 2018-01-31 | 2018-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-31 | 2018-03-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-01-31 | 2018-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-31 | 2018-03-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-31 | 2018-03-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-31 | 2018-03-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-20 | 2018-03-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-20 | 2018-03-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-20 | 2018-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-20 | 2018-03-01 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-04-19 | 2017-05-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-19 | 2017-05-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-19 | 2017-05-30 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-19 | 2017-05-30 | Y |
| Keep all essential equipment working safely. | Health | 2017-04-19 | 2017-05-30 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-19 | 2017-05-30 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-19 | 2017-05-30 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-05 | 2016-12-19 | 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 | 2016-11-08 | 2016-12-16 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-11-08 | 2016-12-16 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-11-08 | 2016-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-11-08 | 2016-12-16 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-11-08 | 2016-12-16 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-11-08 | 2016-12-16 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-11-08 | 2016-12-16 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-11-08 | 2016-12-16 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-11-08 | 2016-12-16 | N |
| 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compe | Health | 2016-11-08 | 2016-12-16 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-11-08 | 2016-12-16 | N |
