Deficiency Records for Koester Pavilion
Updated as of February 01, 2019
This is not the most recent data for Koester Pavilion. For the most recent information, click here.
A list of the most recent deficiencies for Koester Pavilion. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-04 | 2018-10-25 | Y |
| 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 | 2018-07-16 | 2018-08-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-07-16 | 2018-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-16 | 2018-08-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-19 | 2018-08-17 | 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 | 2018-07-19 | 2018-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-19 | 2018-08-17 | 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 | 2018-07-19 | 2018-08-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-07-19 | 2018-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-19 | 2018-08-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-19 | 2018-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-19 | 2018-08-17 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-05-17 | 2017-07-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-05-17 | 2017-07-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-05-17 | 2017-07-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-05-17 | 2017-07-15 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-05-18 | 2017-07-15 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-05-18 | 2017-07-15 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-05-18 | 2017-07-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-05-18 | 2017-07-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-02-02 | 2017-03-10 | Y |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Proper backup exit lighting. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Exits that are free from obstructions and can be used at all times. | Fire Safety | 2016-03-10 | 2016-04-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2016-03-10 | 2016-04-15 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-03-10 | 2016-04-15 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-03-10 | 2016-04-15 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-03-10 | 2016-04-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-03-10 | 2016-04-15 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-03-10 | 2016-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-03-10 | 2016-04-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-03-10 | 2016-04-15 | N |
