Deficiency Records for Tierra Rose Care Center
Updated as of November 01, 2020
This is not the most recent data for Tierra Rose Care Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-06 | 2020-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-06 | 2020-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-22 | 2019-11-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-22 | 2019-10-24 | 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 |
| 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 |
| 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 |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-26 | 2019-07-16 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-21 | 2019-03-22 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-21 | 2019-03-22 | 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 | 2019-02-21 | 2019-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-21 | 2019-03-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-21 | 2019-03-22 | 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 | 2019-02-21 | 2019-03-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-21 | 2019-03-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-02-21 | 2019-03-22 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-02-21 | 2019-03-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-21 | 2019-03-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-06 | 2018-10-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-06 | 2018-10-09 | 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 | 2018-09-06 | 2018-10-09 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-09-06 | 2018-10-09 | Y |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2018-09-06 | 2018-10-09 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-09-06 | 2018-10-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-01-22 | 2018-04-18 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Develop a communication plan. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-18 | 2018-03-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-01-22 | 2018-03-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-22 | 2018-03-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-01-22 | 2018-03-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-01-22 | 2018-03-13 | 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 | 2018-01-22 | 2018-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-22 | 2018-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-22 | 2018-03-13 | 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 | 2018-01-22 | 2018-03-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-22 | 2018-03-13 | 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 | 2018-01-22 | 2018-03-13 | 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 | 2018-01-22 | 2018-03-13 | N |
| Provide or obtain dental services for each resident. | Health | 2018-01-22 | 2018-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-22 | 2018-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-22 | 2018-03-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-01-22 | 2018-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-22 | 2018-03-13 | N |
| Keep all essential equipment working safely. | Health | 2018-01-22 | 2018-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-18 | 2018-02-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-18 | 2018-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-18 | 2018-01-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2016-12-02 | 2017-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2016-12-02 | 2017-01-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-12-05 | 2017-01-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-05 | 2017-01-13 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-12-05 | 2017-01-13 | 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 | 2016-12-05 | 2017-01-13 | 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 | 2016-12-05 | 2017-01-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-12-05 | 2017-01-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-05 | 2017-01-13 | N |
| Provide housekeeping and maintenance services. | Health | 2016-12-05 | 2017-01-13 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-12-05 | 2017-01-13 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-12-05 | 2017-01-13 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-05 | 2017-01-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-12-05 | 2017-01-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2016-12-05 | 2017-01-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-05 | 2017-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-05 | 2017-01-13 | 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 | 2016-12-05 | 2017-01-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-05 | 2017-01-13 | N |
| Keep all essential equipment working safely. | Health | 2016-12-05 | 2017-01-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-05 | 2017-01-13 | N |
