Deficiency Records for Calibre Post Acute, LLC
Updated as of October 01, 2020
This is not the most recent data for Calibre Post Acute, LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2020-01-15 | 2020-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-15 | 2020-02-28 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-01-15 | 2020-02-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-15 | 2020-02-21 | 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 | 2020-01-15 | 2020-02-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-15 | 2020-02-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-15 | 2020-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-15 | 2020-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-15 | 2020-02-21 | 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 | 2020-01-15 | 2020-02-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-15 | 2020-02-21 | 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 | 2020-01-15 | 2020-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-15 | 2020-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-15 | 2020-02-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-15 | 2020-02-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-15 | 2020-02-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-15 | 2020-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-09 | 2019-02-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-01-09 | 2019-02-14 | 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 | 2019-01-15 | 2019-02-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-15 | 2019-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-15 | 2019-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-15 | 2019-02-14 | 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 | 2019-01-15 | 2019-02-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-15 | 2019-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-15 | 2019-02-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-15 | 2019-02-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-15 | 2019-02-14 | 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 | 2019-01-15 | 2019-02-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-01-15 | 2019-02-14 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-01-15 | 2019-02-14 | 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 | 2019-01-15 | 2019-02-14 | 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 | 2019-01-15 | 2019-02-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-15 | 2019-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-15 | 2019-02-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-01-15 | 2019-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-15 | 2019-02-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-15 | 2019-02-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-05 | 2018-02-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-02-05 | 2018-02-28 | 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 | 2018-02-05 | 2018-02-28 | N |
| Respond appropriately to all alleged violations. | Health | 2018-02-05 | 2018-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-05 | 2018-02-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-02-05 | 2018-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-05 | 2018-02-28 | 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 | 2018-02-05 | 2018-02-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-02-05 | 2018-02-28 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-02-05 | 2018-02-28 | 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 | 2018-02-05 | 2018-02-28 | 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 | 2018-02-05 | 2018-02-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-02-05 | 2018-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-05 | 2018-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-05 | 2018-02-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-02-05 | 2018-02-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-02-05 | 2018-02-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-05 | 2018-02-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-02-05 | 2018-02-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-02-05 | 2018-02-28 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-07 | 2018-02-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-02-07 | 2018-02-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-07 | 2018-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-07 | 2018-02-26 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-02-07 | 2018-02-26 | N |