A list of the most recent deficiencies for Abbotts Creek Center. 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? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-11 | 2024-02-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-13 | 2024-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-13 | 2024-01-10 | 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 | 2023-12-13 | 2024-01-10 | 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 | 2023-12-13 | 2024-01-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-13 | 2024-01-10 | N |
| Meet other general requirements. | Fire Safety | 2022-08-11 | 2022-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-11 | 2022-08-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-11 | 2022-08-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-11 | 2022-08-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-11 | 2022-08-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-11 | 2022-08-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-11 | 2022-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-11 | 2022-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-11 | 2022-08-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-11 | 2022-08-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-11 | 2022-08-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-11 | 2022-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-08-01 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-04-06 | 2022-04-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-05 | 2021-02-26 | 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 | 2021-02-05 | 2021-02-26 | 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 | 2021-02-05 | 2021-02-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-02-05 | 2021-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-05 | 2021-02-26 | N |
