Deficiency Records for Llanfair House Care and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Llanfair House Care and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-09 | 2024-01-09 | 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 | 2023-11-09 | 2024-01-09 | 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 | 2023-11-09 | 2024-01-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-09 | 2024-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-09 | 2024-01-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-09 | 2024-01-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-09 | 2024-01-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-11-09 | 2024-01-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-09 | 2024-01-09 | 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 | 2023-11-09 | 2024-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-09 | 2024-01-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-09 | 2024-01-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-09 | 2024-01-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-09 | 2024-01-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-09 | 2024-01-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-09 | 2024-01-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-04 | 2023-06-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-03 | 2023-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-03 | 2023-01-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-03 | 2023-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-03 | 2023-01-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-03 | 2023-01-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-03 | 2023-01-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-03 | 2023-01-20 | 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 | 2022-11-03 | 2023-01-20 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-03 | 2023-01-20 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-11-03 | 2023-01-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-03 | 2023-01-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-03 | 2023-01-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-11-03 | 2023-01-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-03 | 2023-01-20 | 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 | 2022-11-03 | 2023-01-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-03 | 2023-01-20 | 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 | 2022-11-03 | 2023-01-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2023-01-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-03 | 2022-11-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-22 | 2021-08-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-22 | 2021-08-31 | 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 | 2021-07-22 | 2021-08-31 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2020-10-30 | 2020-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-30 | 2020-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-30 | 2020-11-24 | N |
