A list of the most recent deficiencies for Complete Care at Harston Hall LLC. 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 that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-21 | 2023-11-10 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-21 | 2023-10-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-21 | 2023-10-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-21 | 2023-10-20 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-21 | 2023-10-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-21 | 2023-10-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-21 | 2023-10-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-09-21 | 2023-10-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-10-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-21 | 2023-10-20 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-09-21 | 2023-10-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-10-20 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-10-20 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-21 | 2023-10-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-21 | 2023-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-10-20 | 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 | 2023-09-21 | 2023-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-21 | 2023-10-20 | N |
| 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 | 2023-09-21 | 2023-10-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-21 | 2023-10-20 | 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 | 2023-09-21 | 2023-10-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-21 | 2023-10-20 | N |
| Post nurse staffing information every day. | Health | 2023-09-21 | 2023-10-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-20 | 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 | 2023-09-21 | 2023-10-20 | 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 | 2023-09-21 | 2023-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-21 | 2023-10-20 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-21 | 2023-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-21 | 2023-10-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-21 | 2023-10-20 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-09-21 | 2023-10-20 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-21 | 2023-10-20 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-09-21 | 2023-10-20 | 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 | 2023-06-28 | 2023-07-20 | 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 | 2023-01-20 | 2023-02-15 | 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 | 2022-11-21 | 2022-12-16 | 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 | 2022-11-21 | 2022-12-16 | N |
| 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 | 2022-11-21 | 2022-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-21 | 2022-12-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-21 | 2022-12-16 | 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 | 2022-11-21 | 2022-12-16 | 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 | 2022-11-21 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-21 | 2022-12-16 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-21 | 2022-12-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-21 | 2022-12-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-21 | 2022-12-16 | 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 | 2021-11-02 | 2021-12-28 | 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 | 2021-11-02 | 2021-12-28 | N |
