A list of the most recent deficiencies for Complete Care at Inglemoor, LLC. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-26 | 2023-03-15 | 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 | 2023-01-26 | 2023-03-15 | N |
| Post nurse staffing information every day. | Health | 2023-01-26 | 2023-03-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-26 | 2023-03-15 | 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 | 2023-01-26 | 2023-03-15 | 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 | 2023-01-26 | 2023-03-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-26 | 2023-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-26 | 2023-03-15 | N |
| Dispose of garbage and refuse properly. | Health | 2023-01-26 | 2023-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-03-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-26 | 2023-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-26 | 2023-03-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-26 | 2023-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-26 | 2023-03-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-26 | 2023-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-21 | 2022-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-05 | 2021-07-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-05 | 2021-07-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-05 | 2021-06-11 | 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 | 2021-05-05 | 2021-06-11 | 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 | 2021-05-05 | 2021-06-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-05-05 | 2021-06-11 | 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 | 2021-05-05 | 2021-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-05 | 2021-06-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-05 | 2021-06-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-05 | 2021-06-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-26 | 2019-08-13 | 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 | 2019-06-26 | 2019-08-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-26 | 2019-08-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-26 | 2019-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-26 | 2019-08-13 | 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 | 2019-06-26 | 2019-08-13 | 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 | 2019-06-26 | 2019-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-26 | 2019-08-13 | N |
