A list of the most recent deficiencies for Tierra Rose Care 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-19 | 2023-05-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-19 | 2023-05-16 | N |
| Meet other general requirements. | Fire Safety | 2023-04-19 | 2023-05-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-21 | 2023-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-21 | 2023-05-10 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-04-21 | 2023-05-10 | 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 | 2023-04-21 | 2023-05-10 | 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 | 2023-04-21 | 2023-05-10 | 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 | 2023-04-21 | 2023-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-21 | 2023-05-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-10 | Y |
| 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 | 2023-04-21 | 2023-05-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-21 | 2023-05-10 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-21 | 2023-05-10 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-04-21 | 2023-05-10 | 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 | 2023-01-11 | 2023-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-11 | 2023-02-23 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-11 | 2023-02-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-02-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-11 | 2023-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-02-23 | Y |
| 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 | 2023-01-11 | 2023-02-23 | Y |
| 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 | 2023-01-11 | 2023-02-23 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-01-11 | 2023-02-23 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-11 | 2023-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-11 | 2023-02-23 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-11 | 2023-02-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-11 | 2023-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-23 | Y |
| Provide training in compliance and ethics. | Health | 2023-01-11 | 2023-02-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-28 | 2022-05-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-28 | 2022-05-12 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-28 | 2022-05-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-03-28 | 2022-05-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-28 | 2022-05-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-28 | 2022-05-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-28 | 2022-05-12 | 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 | 2022-03-28 | 2022-05-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-28 | 2022-05-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-28 | 2022-05-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-28 | 2022-05-12 | 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 | 2022-03-28 | 2022-05-12 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-28 | 2022-05-12 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-03-28 | 2022-05-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-28 | 2022-05-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-28 | 2022-05-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-28 | 2022-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-28 | 2022-05-12 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-28 | 2022-05-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-28 | 2022-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-28 | 2022-05-12 | 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 | 2022-03-28 | 2022-05-12 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-28 | 2022-05-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-28 | 2022-04-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-28 | 2022-04-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-17 | 2022-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-17 | 2022-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-17 | 2022-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-17 | 2022-04-28 | N |
| Meet other general requirements. | Fire Safety | 2022-03-17 | 2022-04-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-28 | 2022-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-28 | 2022-04-22 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-28 | 2022-04-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-25 | 2021-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-25 | 2021-08-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-25 | 2021-08-10 | 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 | 2021-04-14 | 2021-05-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-14 | 2021-05-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-14 | 2021-05-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-14 | 2021-05-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-14 | 2021-05-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-14 | 2021-05-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-14 | 2021-05-14 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-04-14 | 2021-05-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-14 | 2021-05-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-14 | 2021-05-14 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-04-14 | 2021-05-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-14 | 2021-04-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-02 | 2021-03-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-02 | 2021-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-02 | 2021-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-02 | 2021-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-26 | 2019-09-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-29 | 2019-08-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-07-26 | 2019-08-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-26 | 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 | 2019-07-26 | 2019-08-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-26 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-26 | 2019-08-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-07-26 | 2019-08-16 | 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 | 2019-07-26 | 2019-08-16 | N |
| Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. | Health | 2019-07-26 | 2019-08-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-26 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-26 | 2019-08-16 | N |
| Keep all essential equipment working safely. | Health | 2019-07-26 | 2019-08-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-07-26 | 2019-08-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-07-29 | 2019-08-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-07-29 | 2019-08-16 | 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 | 2019-07-29 | 2019-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-29 | 2019-08-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-29 | 2019-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-29 | 2019-08-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-07-29 | 2019-08-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-29 | 2019-08-16 | N |
