A list of the most recent deficiencies for Convalarium at Indian Run. 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 care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-11 | 2023-09-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-11 | 2023-09-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-05 | 2023-07-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-30 | 2023-04-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-16 | 2023-03-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-31 | 2023-03-10 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2023-01-31 | 2023-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-31 | 2023-03-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-30 | 2023-02-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-26 | 2022-11-16 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-26 | 2022-11-16 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-10-05 | 2022-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-05 | 2022-11-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-12 | 2022-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-12 | 2022-11-16 | 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 | 2022-09-12 | 2022-11-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-19 | 2022-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-19 | 2022-11-16 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-27 | 2022-08-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-10 | 2022-06-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-10 | 2022-06-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-10 | 2022-06-23 | 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 | 2022-05-10 | 2022-06-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-10 | 2022-06-23 | 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 | 2022-05-10 | 2022-06-23 | 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 | 2022-05-10 | 2022-06-23 | 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 | 2022-05-10 | 2022-06-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-10 | 2022-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-10 | 2022-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-10 | 2022-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-10 | 2022-06-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-10 | 2022-06-23 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-05-10 | 2022-06-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-04 | 2022-06-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-04 | 2022-06-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-04-27 | 2022-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-04 | 2022-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-04 | 2022-02-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-04 | 2022-02-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-07 | 2021-11-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-27 | 2021-09-10 | Y |
| 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 | 2021-08-27 | 2021-09-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-26 | 2020-01-03 | 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 | 2019-11-26 | 2020-01-03 | 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 | 2019-11-26 | 2020-01-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-26 | 2020-01-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-26 | 2020-01-03 | 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 | 2019-11-26 | 2020-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-26 | 2020-01-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-26 | 2020-01-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-26 | 2020-01-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-26 | 2020-01-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-26 | 2020-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-26 | 2020-01-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-13 | 2019-01-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-13 | 2019-01-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-12-13 | 2019-01-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-13 | 2019-01-11 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2018-12-13 | 2019-01-11 | N |
| Provide or obtain dental services for each resident. | Health | 2018-12-13 | 2019-01-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-12-13 | 2019-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-13 | 2019-01-11 | 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 | 2018-12-11 | 2019-01-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-11 | 2019-01-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-11 | 2019-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-11 | 2019-01-11 | N |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2018-12-11 | 2019-01-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-07 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-07 | Not Fixed | N |
