Deficiency Records for Buckeye Terrace Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Buckeye Terrace Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| 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 | 2024-02-09 | 2024-02-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-12 | 2023-12-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-12 | 2023-12-29 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-12-12 | 2023-12-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-13 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-13 | 2023-10-27 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-13 | 2023-10-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-13 | 2023-10-27 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-14 | 2023-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-27 | 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 | 2023-09-14 | 2023-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-14 | 2023-10-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-27 | N |
| 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 | 2023-09-14 | 2023-10-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-14 | 2023-10-27 | 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 | 2023-09-14 | 2023-10-27 | 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 | 2023-09-14 | 2023-10-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-09-14 | 2023-10-27 | 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 | 2023-09-13 | 2023-10-27 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-13 | 2023-10-27 | 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 | 2023-09-13 | 2023-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-13 | 2023-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-13 | 2023-10-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-13 | 2023-10-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-09-13 | 2023-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-13 | 2023-10-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-06 | 2023-09-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-06 | 2023-09-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-06 | 2023-09-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-13 | 2023-04-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-13 | 2023-04-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-06 | 2023-03-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-06 | 2023-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-06 | 2023-03-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-06 | 2023-03-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-06 | 2023-03-21 | 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 | 2023-03-06 | 2023-03-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-06 | 2023-03-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-06 | 2023-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-06 | 2023-03-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-06 | 2023-03-21 | Y |
| 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 | 2023-02-08 | 2023-03-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-13 | 2023-03-21 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-02-17 | 2022-03-07 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-12-01 | 2022-01-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-01 | 2022-01-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-01 | 2022-01-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-12-01 | 2022-01-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-01 | 2022-01-13 | 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 | 2021-12-01 | 2022-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-01 | 2022-01-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-01 | 2022-01-13 | 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 | 2021-12-01 | 2022-01-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-01 | 2022-01-13 | 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 | 2021-12-01 | 2022-01-13 | 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 | 2021-12-01 | 2022-01-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-01 | 2022-01-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-01 | 2022-01-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-01 | 2022-01-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-01 | 2022-01-13 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-01 | 2022-01-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-01 | 2022-01-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-01 | 2022-01-13 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-01 | 2022-01-13 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-12-01 | 2022-01-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-01 | 2022-01-13 | 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 | 2021-11-22 | 2022-01-13 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-22 | 2022-01-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-08 | 2021-10-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-08 | 2021-10-28 | 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 | 2021-10-08 | 2021-10-28 | Y |
| 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 | 2021-10-08 | 2021-10-28 | Y |
| Post nurse staffing information every day. | Health | 2021-10-08 | 2021-10-28 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-08 | 2021-10-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-08 | 2021-10-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-07 | 2021-06-16 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-07-03 | 2019-08-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-07-03 | 2019-08-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-03 | 2019-08-16 | 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 | 2019-07-03 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-03 | 2019-08-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-03 | 2019-08-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-03 | 2019-08-16 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-07-03 | 2019-08-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-03 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-03 | 2019-08-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-03 | 2019-08-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-03 | 2019-08-16 | 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 | 2019-07-03 | 2019-08-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-03 | 2019-08-16 | 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 | 2019-07-03 | 2019-08-16 | 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 | 2019-07-03 | 2019-08-16 | 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 | 2019-07-03 | 2019-08-16 | N |
| Provide or obtain dental services for each resident. | Health | 2019-07-03 | 2019-08-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-07-03 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-03 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-03 | 2019-08-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-03 | 2019-08-16 | N |
