A list of the most recent deficiencies for Pembroke 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? |
|---|---|---|---|---|
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-16 | 2023-12-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-16 | 2023-12-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2023-12-14 | Y |
| 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 | 2023-11-16 | 2023-12-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-16 | 2023-12-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-07 | 2023-08-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-20 | 2023-08-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-08-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-20 | 2023-08-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-08-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-29 | 2023-08-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-31 | 2023-06-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-31 | 2023-06-29 | 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 | 2023-02-08 | 2023-02-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-08 | 2023-02-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-08 | 2023-02-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-08 | 2023-02-23 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-07-25 | 2022-08-12 | 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 | 2022-07-25 | 2022-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide appropriate foot care. | Health | 2022-07-25 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-25 | 2022-08-12 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2022-07-25 | 2022-08-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-06 | 2021-07-23 | Y |
| 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 | 2021-07-06 | 2021-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-06 | 2021-07-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-06 | 2021-07-23 | 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 | 2021-07-06 | 2021-07-23 | 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 | 2021-07-06 | 2021-07-23 | 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 | 2021-07-06 | 2021-07-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-06 | 2021-07-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-06 | 2021-07-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-06 | 2021-07-23 | Y |
| 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 | 2021-07-06 | 2021-07-23 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-04 | 2019-06-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-04 | 2019-06-22 | N |
