Deficiency Records for Medical Park West Rehabilitation and Skilled Care
Updated as of March 01, 2024
A list of the most recent deficiencies for Medical Park West Rehabilitation and Skilled Care. 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? |
|---|---|---|---|---|
| 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 | 2024-01-18 | 2024-01-29 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-07 | 2023-12-06 | 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 | 2023-11-07 | 2023-12-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-07 | 2023-12-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-07 | 2023-12-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-07 | 2023-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-07 | 2023-12-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-07 | 2023-12-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-07 | 2023-12-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-07 | 2023-12-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-07 | 2023-12-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-07 | 2023-12-06 | 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 | 2023-11-07 | 2023-12-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-07 | 2023-12-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-07 | 2023-12-06 | 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 | 2023-11-07 | 2023-12-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-07 | 2023-12-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-11-07 | 2023-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-12-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-07 | 2023-12-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-08 | 2023-08-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-15 | 2023-06-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-09 | 2023-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-09 | 2023-04-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-04-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-09 | 2023-04-07 | 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 | 2023-03-09 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-04 | 2022-11-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-04 | 2022-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-04 | 2022-11-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-04 | 2022-11-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-04 | 2022-11-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-04 | 2022-11-08 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-04 | 2022-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-04 | 2022-11-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-29 | 2022-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-29 | 2022-11-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-29 | 2022-11-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-04 | 2022-08-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-16 | 2022-04-05 | Y |
| 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 | 2022-02-19 | 2022-03-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-19 | 2022-03-16 | 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 | 2022-02-19 | 2022-03-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-03-08 | 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 | 2022-01-27 | 2022-03-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-27 | 2022-03-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-09 | 2021-10-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-08-09 | 2021-10-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-09 | 2021-10-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-09 | 2021-10-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-09 | 2021-10-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-09 | 2021-10-05 | Y |
| 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 | 2021-08-09 | 2021-10-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-09 | 2021-10-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-09 | 2021-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-09 | 2021-10-05 | Y |
| 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 | 2021-08-09 | 2021-10-05 | 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 | 2021-08-09 | 2021-10-05 | 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 | 2021-08-09 | 2021-10-05 | 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 | 2021-08-09 | 2021-10-05 | Y |
| 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 | 2021-08-09 | 2021-10-05 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2021-08-09 | 2021-10-05 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-08-09 | 2021-10-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-09 | 2021-10-05 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-08-09 | 2021-10-05 | 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 | 2021-08-09 | 2021-10-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-10 | 2021-04-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-10 | 2021-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-10 | 2021-04-16 | Y |
| 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 | 2021-03-10 | 2021-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-10 | 2021-04-16 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-27 | 2019-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-27 | 2019-04-11 | N |
