Deficiency Records for Lewis and Clark Gardens
Updated as of November 01, 2019
This is not the most recent data for Lewis and Clark Gardens. For the most recent information, click here.
A list of the most recent deficiencies for Lewis and Clark Gardens. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Meet other general requirements. | Fire Safety | 2019-06-18 | 2019-07-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-06-18 | 2019-07-31 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-06-18 | 2019-07-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-18 | 2019-07-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-18 | 2019-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-18 | 2019-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-18 | 2019-07-31 | N |
| 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 | 2019-06-18 | 2019-07-31 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | 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 | 2019-06-18 | 2019-07-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-06-18 | 2019-07-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-18 | 2019-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-18 | 2019-07-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-19 | 2019-01-02 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-11-19 | 2019-01-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-19 | 2019-01-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-19 | 2019-01-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-01 | 2018-08-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-30 | 2018-07-11 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Meet other general requirements. | Fire Safety | 2018-03-21 | 2018-05-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-21 | 2018-05-03 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-03-21 | 2018-05-03 | 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 | 2018-03-21 | 2018-05-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-21 | 2018-05-03 | 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 | 2018-03-21 | 2018-05-03 | N |
| 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 | 2018-03-21 | 2018-05-03 | 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 | 2018-03-21 | 2018-05-03 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-03-21 | 2018-05-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-03-21 | 2018-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-21 | 2018-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-21 | 2018-05-03 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-01-19 | 2017-12-14 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Meet other general requirements. | Fire Safety | 2017-04-04 | 2017-05-15 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-04-04 | 2017-05-15 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-04-04 | 2017-05-15 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-04-04 | 2017-05-15 | N |
| Provide housekeeping and maintenance services. | Health | 2017-04-04 | 2017-05-15 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-04 | 2017-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-04 | 2017-05-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-04 | 2017-05-15 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-04-04 | 2017-05-15 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-04-04 | 2017-05-15 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-04-04 | 2017-05-15 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-04-04 | 2017-05-15 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-04-04 | 2017-05-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-04 | 2017-05-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-04 | 2017-05-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-04 | 2017-05-15 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-04-04 | 2017-05-15 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-04-04 | 2017-05-15 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-04 | 2017-05-15 | Y |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-04-04 | 2017-05-15 | Y |
| Provide clean bed and bath linens that are in good condition. | Health | 2017-04-04 | 2017-05-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-04 | 2017-05-15 | Y |
