A list of the most recent deficiencies for Mckendree Village. 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? |
|---|---|---|---|---|
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-10-03 | 2024-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-03 | 2023-11-14 | 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 | 2023-10-03 | 2023-11-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-03 | 2023-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-18 | 2023-11-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-18 | 2023-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-18 | 2023-11-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-09-18 | 2023-11-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-18 | 2023-11-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-18 | 2023-11-13 | N |
| Keep all essential equipment working safely. | Health | 2023-10-03 | 2023-11-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-03 | 2023-11-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-03 | 2023-11-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-03 | 2023-11-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-03 | 2023-11-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-03 | 2023-11-03 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-03 | 2023-11-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-03 | 2023-11-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-10-03 | 2023-11-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-03 | 2023-11-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-03 | 2023-11-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-03 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-03 | 2023-11-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-11-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-03 | 2023-11-03 | N |
| 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 | 2023-10-03 | 2023-11-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-03 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-03 | 2023-11-03 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-03 | 2023-11-02 | 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 | 2023-10-03 | 2023-11-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-03 | 2023-11-01 | 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 | 2023-10-03 | 2023-11-01 | 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 | 2022-12-16 | 2023-01-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-16 | 2023-01-17 | Y |
| 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 | 2022-12-16 | 2023-01-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-16 | 2023-01-17 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2022-12-16 | 2023-01-17 | Y |
| 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 | 2022-12-16 | 2023-01-17 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-12-16 | 2023-01-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-16 | 2023-01-17 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-12-16 | 2023-01-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-16 | 2023-01-17 | 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 | 2019-06-19 | 2019-08-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-19 | 2019-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-19 | 2019-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-19 | 2019-08-02 | N |
| Keep all essential equipment working safely. | Health | 2019-06-19 | 2019-08-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Develop a communication plan. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Establish methods for sharing information. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-19 | 2019-08-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-19 | 2019-07-23 | 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 | 2018-06-06 | 2018-07-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-06-06 | 2018-07-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-06-06 | 2018-07-20 | 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 | 2018-06-06 | 2018-07-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-06-05 | 2018-06-20 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2018-06-05 | 2018-06-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-06-05 | 2018-06-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-05 | 2018-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-05 | 2018-06-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-06-05 | 2018-06-20 | N |
