A list of the most recent deficiencies for Calibre Post Acute, 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-01-03 | 2024-01-17 | Y |
| 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 | 2023-08-03 | 2024-01-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-03 | 2024-01-16 | 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 | 2023-08-03 | 2024-01-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-03 | 2024-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-03 | 2024-01-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-03 | 2023-09-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-03 | 2023-09-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-03 | 2023-09-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-03 | 2023-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-03 | 2023-09-02 | 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 | 2023-08-03 | 2023-09-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-03 | 2023-09-02 | 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 | 2023-08-03 | 2023-09-02 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-03 | 2023-09-02 | 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 | 2023-08-03 | 2023-09-02 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-03 | 2023-09-02 | 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 | 2023-08-03 | 2023-09-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-03 | 2023-09-02 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-03 | 2023-09-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-03 | 2023-09-02 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-08-03 | 2023-09-02 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-28 | 2023-09-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-28 | 2023-09-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-28 | 2023-09-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-28 | 2023-09-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-09 | 2022-10-07 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-09-09 | 2022-10-07 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-09-09 | 2022-10-07 | 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 | 2022-09-09 | 2022-10-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-09 | 2022-10-07 | 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 | 2022-09-09 | 2022-10-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-09 | 2022-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-09 | 2022-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-09 | 2022-10-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-09 | 2022-10-07 | 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 | 2022-09-09 | 2022-10-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-09 | 2022-10-07 | 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 | 2022-09-09 | 2022-10-07 | 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 | 2022-09-09 | 2022-10-07 | 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 | 2022-09-09 | 2022-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-10-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-09-09 | 2022-10-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-09-09 | 2022-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-09 | 2022-10-07 | N |
| Keep all essential equipment working safely. | Health | 2022-09-09 | 2022-10-07 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-09 | 2022-10-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-30 | 2022-10-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-08 | 2022-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-24 | 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 | 2022-04-08 | 2022-05-24 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-08 | 2022-05-24 | Y |
| 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 | 2022-04-08 | 2022-05-24 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-04-08 | 2022-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2021-12-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-10 | 2021-12-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-11-10 | 2021-12-03 | Y |
| 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 | 2021-11-10 | 2021-12-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-10 | 2021-12-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-10 | 2021-12-03 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-10 | 2021-12-03 | Y |
| Keep all essential equipment working safely. | Health | 2021-11-10 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-12-03 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-09-17 | 2021-12-03 | Y |
| Keep all essential equipment working safely. | Health | 2021-09-17 | 2021-12-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-24 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-12-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-17 | 2021-10-22 | Y |
| 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 | 2021-09-17 | 2021-10-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-09-17 | 2021-10-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-17 | 2021-10-22 | Y |
| 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 | 2021-09-17 | 2021-10-22 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-09-17 | 2021-10-22 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-29 | 2021-08-19 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-06-24 | 2021-08-09 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-06-24 | 2021-08-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-24 | 2021-08-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-24 | 2021-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-24 | 2021-08-09 | 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 | 2021-06-24 | 2021-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-24 | 2021-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-24 | 2021-08-09 | 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 | 2021-06-24 | 2021-08-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-24 | 2021-08-09 | 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 | 2021-06-24 | 2021-08-09 | 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 | 2021-06-24 | 2021-08-09 | N |
| Post nurse staffing information every day. | Health | 2021-06-24 | 2021-08-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-24 | 2021-08-09 | 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 | 2021-06-24 | 2021-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-08-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-24 | 2021-08-09 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-24 | 2021-08-09 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-29 | 2021-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-29 | 2021-07-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-29 | 2021-07-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-29 | 2021-07-16 | N |
