A list of the most recent deficiencies for Renaissance Terrace. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-20 | 2023-10-13 | N |
| 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 | 2023-09-20 | 2023-10-13 | 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 | 2023-09-20 | 2023-10-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-20 | 2023-10-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-20 | 2023-10-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-20 | 2023-10-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-20 | 2023-10-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-09-20 | 2023-10-13 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-20 | 2023-10-13 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-09-20 | 2023-10-13 | 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 | 2023-09-20 | 2023-10-13 | Y |
| Post nurse staffing information every day. | Health | 2023-09-20 | 2023-10-13 | Y |
| 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 | 2023-09-20 | 2023-10-13 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-09-20 | 2023-10-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-20 | 2023-10-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-20 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-13 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-09-20 | 2023-10-13 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-28 | 2023-10-13 | 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 | 2023-08-28 | 2023-10-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-28 | 2023-10-13 | 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 | 2023-08-28 | 2023-10-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-28 | 2023-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-23 | 2023-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-04-28 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-18 | 2022-04-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-04 | 2020-01-17 | 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 | 2019-12-04 | 2020-01-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-04 | 2020-01-17 | 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 | 2019-12-04 | 2020-01-17 | 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 | 2019-12-02 | 2019-12-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-10-15 | 2018-12-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-17 | 2018-12-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-17 | 2018-12-01 | 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 | 2018-10-17 | 2018-12-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-17 | 2018-12-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-10-15 | 2018-12-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-15 | 2018-12-01 | 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 | 2018-10-15 | 2018-12-01 | 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 | 2018-10-15 | 2018-12-01 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-10-15 | 2018-12-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-15 | 2018-12-01 | N |
