A list of the most recent deficiencies for Eastgate Village Retirement 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-06 | 2023-12-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-06 | 2023-12-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-11-06 | 2023-12-26 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-11-06 | 2023-12-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-06 | 2023-12-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-06 | 2023-12-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-06 | 2023-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-06 | 2023-12-26 | 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 | 2022-04-22 | 2022-06-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-22 | 2022-06-07 | 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 | 2022-04-22 | 2022-06-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-22 | 2022-06-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-04-22 | 2022-05-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-22 | 2022-05-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-04-22 | 2022-05-27 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-04-22 | 2022-05-27 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-04-22 | 2022-05-27 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-06-24 | 2021-08-03 | 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 | 2021-06-24 | 2021-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-24 | 2021-08-03 | Y |
| 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 | 2021-05-25 | 2021-07-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-25 | 2021-07-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-25 | 2021-07-07 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-25 | 2021-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-25 | 2021-07-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-25 | 2021-07-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-25 | 2021-07-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-25 | 2021-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-25 | 2021-07-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-25 | 2021-07-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-25 | 2021-07-07 | 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 | 2021-05-25 | 2021-07-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-25 | 2021-07-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-25 | 2021-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-25 | 2021-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-25 | 2021-07-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-18 | 2021-07-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-18 | 2021-07-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-18 | 2021-07-07 | 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 | 2019-03-06 | 2019-04-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-06 | 2019-04-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-06 | 2019-04-08 | N |
