A list of the most recent deficiencies for Lanessa Extended Care. 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 appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-08 | 2024-01-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-08 | 2024-01-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-08 | 2023-12-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-22 | 2023-12-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-08 | 2023-11-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-08 | 2023-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-08 | 2023-11-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-08 | 2023-11-21 | N |
| 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 | 2023-11-08 | 2023-11-21 | 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 | 2023-11-08 | 2023-11-21 | 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 | 2023-11-08 | 2023-11-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-08 | 2023-11-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-08 | 2023-11-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-11-08 | 2023-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2023-11-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-08 | 2023-11-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-14 | 2023-10-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-07 | 2022-11-09 | 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 | 2022-11-09 | N |
| Provide appropriate foot care. | Health | 2022-09-07 | 2022-11-09 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-07 | 2022-11-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-07 | 2022-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-07 | 2022-11-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-23 | 2022-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-23 | 2022-10-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-07 | 2022-10-14 | 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 | 2022-09-07 | 2022-10-14 | N |
| 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 | 2022-09-07 | 2022-10-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-07 | 2022-10-14 | 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 | 2022-09-07 | 2022-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-07 | 2022-10-14 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-09-07 | 2022-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-07 | 2022-10-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-07 | 2022-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-07 | 2022-10-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-07 | 2022-10-14 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-09-07 | 2022-10-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-07 | 2022-10-14 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-07 | 2022-10-14 | 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 | 2022-09-07 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-07 | 2022-10-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-07 | 2022-10-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-07 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-06 | 2022-08-15 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-04-14 | 2022-05-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-14 | 2022-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-31 | 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 | 2022-04-14 | 2022-05-31 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-14 | 2022-05-31 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-14 | 2022-05-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-14 | 2022-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-01 | 2022-05-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-09 | 2022-05-03 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-09 | 2022-05-03 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-27 | 2022-03-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-27 | 2022-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-03-02 | 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 | 2021-09-29 | 2021-11-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-29 | 2021-11-08 | 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 | 2021-09-29 | 2021-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-29 | 2021-11-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-29 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-11-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-29 | 2021-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-08 | 2021-11-08 | N |
