Deficiency Records for Abbyshire Place Health and Rehabilitation Center L
Updated as of April 01, 2024
A list of the most recent deficiencies for Abbyshire Place Health and Rehabilitation Center L. 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? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-02-12 | 2024-03-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-02-12 | 2024-03-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-12 | 2024-03-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-12 | 2024-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-12 | 2024-03-15 | 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 | 2024-02-12 | 2024-03-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-02-12 | 2024-03-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-12 | 2024-03-15 | 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 | 2024-02-12 | 2024-03-15 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-02-12 | 2024-03-15 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-12 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-12 | 2024-03-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-12 | 2024-03-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-07 | 2024-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-16 | 2022-07-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-16 | 2022-07-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-07-08 | 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 | 2022-06-16 | 2022-07-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-16 | 2022-07-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-13 | 2022-07-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-13 | 2022-07-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-13 | 2022-07-08 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-22 | 2022-03-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-22 | 2022-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-22 | 2022-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-09 | 2019-09-13 | 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 | 2019-08-09 | 2019-09-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-08-09 | 2019-09-13 | 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 | 2019-08-09 | 2019-09-13 | 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 | 2019-08-09 | 2019-09-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-09 | 2019-09-13 | 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 | 2019-08-06 | 2019-09-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-06 | 2019-09-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-06 | 2019-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-06 | 2019-09-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-06 | 2019-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-06 | 2019-09-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-06 | 2019-09-13 | N |
