A list of the most recent deficiencies for Vancrest Health Care 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? |
|---|---|---|---|---|
| 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 | 2023-12-07 | 2024-01-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-13 | 2022-11-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-13 | 2022-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-13 | 2022-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-13 | 2022-11-04 | 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 | 2022-10-13 | 2022-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-13 | 2022-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-04 | N |
| 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 | 2022-10-13 | 2022-11-04 | 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 | 2022-10-13 | 2022-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-13 | 2022-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-13 | 2022-11-04 | N |
| 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 | 2022-10-03 | 2022-11-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-03 | 2022-11-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-03 | 2022-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-03 | 2022-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-03 | 2022-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-03 | 2022-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-11 | 2019-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-11 | 2019-08-30 | N |
| 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 | 2019-07-11 | 2019-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-08 | 2019-08-30 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-08 | 2019-08-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-08 | 2019-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-08 | 2019-08-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-08 | 2019-08-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-08 | 2019-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-14 | 2018-07-23 | 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 | 2018-06-14 | 2018-07-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-06-13 | 2018-07-23 | 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 | 2018-06-13 | 2018-07-23 | N |
