A list of the most recent deficiencies for Communities at Indian Haven. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-20 | 2023-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-20 | 2023-07-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-20 | 2023-07-20 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-05-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-18 | N |
| 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 | 2023-03-16 | 2023-04-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-04-18 | 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 | 2023-03-16 | 2023-04-18 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-03-16 | 2023-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-18 | N |
| Report COVID19 data to residents and families. | Health | 2023-03-16 | 2023-04-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-03-16 | 2023-04-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Meet other general requirements. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-04-28 | 2022-06-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-09 | 2022-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-09 | 2022-05-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-09 | 2022-05-18 | 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 | 2022-04-09 | 2022-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-09 | 2022-05-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-09 | 2022-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-09 | 2022-05-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-09 | 2022-05-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-09 | 2022-05-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-31 | 2021-05-24 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-03-31 | 2021-05-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-31 | 2021-05-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-31 | 2021-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-31 | 2021-05-24 | 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 | 2021-03-31 | 2021-05-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-31 | 2021-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-31 | 2021-05-24 | N |
| 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 | 2021-03-31 | 2021-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-31 | 2021-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-31 | 2021-05-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-03-31 | 2021-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-31 | 2021-05-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-31 | 2021-05-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-26 | 2021-05-13 | 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 | 2021-04-26 | 2021-05-13 | 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 | 2021-04-26 | 2021-05-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-26 | 2021-05-13 | N |
