A list of the most recent deficiencies for Kenwood Terrace Healthcare 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-06 | 2023-12-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-06 | 2023-12-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-23 | 2023-11-21 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-23 | 2023-11-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-23 | 2023-11-21 | 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 | 2023-10-23 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-23 | 2023-11-21 | 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 | 2023-05-17 | 2023-05-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-17 | 2023-03-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-17 | 2023-03-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-05-03 | 2022-07-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-03 | 2022-07-26 | 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 | 2022-05-03 | 2022-07-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-03 | 2022-07-26 | 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 | 2022-05-03 | 2022-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-03 | 2022-07-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-03 | 2022-07-26 | 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 | 2022-05-03 | 2022-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-03 | 2022-07-26 | 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 | 2022-05-03 | 2022-07-26 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-05-03 | 2022-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-03 | 2022-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-03 | 2022-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-03 | 2022-07-26 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-03 | 2022-07-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-07 | 2022-07-26 | 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 | 2022-07-07 | 2022-07-26 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-07-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-04-28 | 2022-07-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-28 | 2022-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-28 | 2022-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-28 | 2022-07-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-04 | 2021-08-31 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-08-04 | 2021-08-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-04 | 2021-08-31 | 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 | 2021-08-04 | 2021-08-31 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-04-16 | 2019-05-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-16 | 2019-05-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-16 | 2019-05-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-04-16 | 2019-05-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-16 | 2019-05-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-16 | 2019-05-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-16 | 2019-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-16 | 2019-05-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-16 | 2019-05-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-16 | 2019-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-01 | 2019-05-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-01 | 2019-05-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-01 | 2019-05-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-04-01 | 2019-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-01 | 2019-05-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-02-22 | 2018-04-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-22 | 2018-04-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-23 | 2018-04-02 | N |
