Deficiency Records for Calibre Post Acute, LLC
Updated as of June 01, 2022
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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 |
