A list of the most recent deficiencies for Country Aire Retirement 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 | 2023-10-05 | 2023-11-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-18 | 2023-04-19 | 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 | 2023-01-18 | 2023-04-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-18 | 2023-04-19 | 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 | 2023-01-18 | 2023-04-19 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-18 | 2023-04-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-18 | 2023-04-19 | 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 | 2023-01-18 | 2023-04-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-18 | 2023-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-18 | 2023-04-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-18 | 2023-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-18 | 2023-04-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-04-19 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-18 | 2023-04-19 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-18 | 2023-03-30 | 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 | 2023-01-18 | 2023-03-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-18 | 2023-03-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-18 | 2023-03-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-18 | 2023-03-30 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-03-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-18 | 2023-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-18 | 2023-03-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-18 | 2023-03-30 | 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 | 2023-01-18 | 2023-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-18 | 2023-03-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-03-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-18 | 2023-03-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-18 | 2023-03-30 | 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 | 2023-01-18 | 2023-03-30 | 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 | 2023-01-18 | 2023-03-30 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-01-18 | 2023-03-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-18 | 2023-03-30 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-01-18 | 2023-03-30 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-18 | 2023-03-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-01-18 | 2023-03-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-18 | 2023-03-30 | 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 | 2023-01-18 | 2023-03-30 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-01-18 | 2023-03-30 | Y |
| Post nurse staffing information every day. | Health | 2023-01-18 | 2023-03-30 | Y |
| 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 | 2023-01-18 | 2023-03-30 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-01-18 | 2023-03-30 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| 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 | 2023-01-18 | 2023-03-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-18 | 2023-03-30 | 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 | 2023-01-18 | 2023-03-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-18 | 2023-03-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-18 | 2023-03-20 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-31 | 2022-09-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-31 | 2022-09-15 | 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 | 2019-05-15 | 2019-06-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-15 | 2019-06-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-15 | 2019-06-07 | 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 | 2018-06-15 | 2018-07-29 | N |
| Use approved construction type or materials. | Fire Safety | 2018-06-15 | 2018-07-29 | N |
| 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 | 2018-06-15 | 2018-07-29 | 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 | 2018-06-15 | 2018-07-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-15 | 2018-07-29 | N |
