Deficiency Records for The Cross Keys Village-Brethren Home Community
Updated as of March 01, 2020
This is not the most recent data for The Cross Keys Village-Brethren Home Community. For the most recent information, click here.
A list of the most recent deficiencies for The Cross Keys Village-Brethren Home Community. 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 each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-08-08 | 2019-11-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-08 | 2019-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-09-23 | 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 | 2019-08-08 | 2019-09-23 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-08-08 | 2019-09-23 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-08-08 | 2019-09-23 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-14 | 2019-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-20 | 2019-07-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-20 | 2019-07-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-20 | 2019-07-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-30 | 2019-05-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-30 | 2019-05-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-30 | 2019-05-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-04-05 | 2019-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-05 | 2019-05-22 | 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 | 2019-04-05 | 2019-05-22 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2019-03-08 | 2019-04-17 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-03-08 | 2019-04-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-08 | 2019-04-17 | 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 | 2019-03-08 | 2019-04-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-25 | 2019-03-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-25 | 2019-03-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-09 | 2018-10-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-09 | 2018-10-08 | 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 | 2018-08-09 | 2018-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-09 | 2018-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-09 | 2018-10-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-08-09 | 2018-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-09 | 2018-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-09 | 2018-10-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-08-09 | 2018-10-08 | 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 ne | Health | 2018-08-09 | 2018-10-08 | 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 | 2018-08-09 | 2018-10-08 | N |
| Provide or obtain dental services for each resident. | Health | 2018-08-09 | 2018-10-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-08-09 | 2018-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-09 | 2018-10-08 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-08-09 | 2018-10-08 | 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 | 2018-08-09 | 2018-10-08 | 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 | 2018-08-09 | 2018-10-08 | 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 | 2018-08-09 | 2018-10-08 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-08-22 | 2018-10-01 | 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 | 2018-08-22 | 2018-10-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-22 | 2018-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-09-26 | 2017-11-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-09-26 | 2017-11-13 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-09-21 | 2017-11-13 | 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 | 2017-09-21 | 2017-11-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-09-21 | 2017-11-13 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-09-21 | 2017-11-13 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-09-21 | 2017-11-13 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-21 | 2017-11-13 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-21 | 2017-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-21 | 2017-11-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-21 | 2017-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-21 | 2017-11-13 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-09-21 | 2017-11-13 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-09-21 | 2017-11-13 | N |
| Make sure that paid feeding assistants 1) completed training; 2) work under the supervision of a RN or LPN; and 3) feed only residents who have no complicated feeding problems. | Health | 2017-09-21 | 2017-11-13 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-09-21 | 2017-11-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-21 | 2017-11-13 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2017-09-21 | 2017-11-13 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-09-21 | 2017-11-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-09-21 | 2017-11-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-10 | 2017-06-09 | Y |
