A list of the most recent deficiencies for Kirtland Rehabilitation and Care. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-12-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-12-07 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-07-20 | 2023-12-06 | 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 | 2023-07-20 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-20 | 2023-12-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-28 | 2023-11-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-28 | 2023-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-28 | 2023-11-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-28 | 2023-11-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-20 | 2023-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-11-15 | 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 | 2023-07-20 | 2023-11-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-20 | 2023-11-15 | 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 | 2023-07-20 | 2023-11-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-20 | 2023-11-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-20 | 2023-11-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-02 | 2023-09-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-02 | 2023-09-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-27 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-27 | 2023-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-27 | 2023-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-21 | 2023-02-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-29 | 2023-01-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-29 | 2023-01-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-21 | 2021-11-19 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-10-21 | 2021-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2021-11-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-10-21 | 2021-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-21 | 2021-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-09 | 2021-11-19 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-09 | 2021-10-21 | 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 | 2021-09-09 | 2021-10-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-09 | 2021-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-10-21 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-09 | 2021-10-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-09 | 2021-07-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-19 | 2019-05-08 | 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 | 2019-03-19 | 2019-05-08 | 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 | 2019-03-19 | 2019-05-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-03-19 | 2019-05-08 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2019-03-19 | 2019-05-08 | 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 | 2019-03-19 | 2019-05-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-19 | 2019-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-19 | 2019-05-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-19 | 2019-05-08 | N |
