A list of the most recent deficiencies for Kirkhaven. 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 and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-16 | 2023-05-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-16 | 2023-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-16 | 2023-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-05-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-16 | 2023-05-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-16 | 2023-05-15 | Y |
| Develop a communication plan. | Fire Safety | 2023-03-16 | 2023-05-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-16 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-05-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-03-16 | 2023-05-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-16 | 2023-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-02 | 2021-06-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-02 | 2021-06-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-04-02 | 2021-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-02 | 2021-06-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-02 | 2021-06-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-04-02 | 2021-06-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-05 | 2019-05-04 | 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 | 2019-03-05 | 2019-05-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-05 | 2019-05-04 | 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 | 2019-03-05 | 2019-05-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-05 | 2019-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-05 | 2019-05-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-05 | 2019-05-04 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-03-05 | 2019-05-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-03-05 | 2019-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-05 | 2019-05-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-05 | 2019-05-04 | N |
