Deficiency Records for Collierville Nursing and Rehabilitation, LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Collierville Nursing and Rehabilitation, 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? |
|---|---|---|---|---|
| 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 | 2022-12-09 | 2022-12-29 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-09 | 2022-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-29 | 2022-12-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-17 | 2022-09-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-17 | 2022-09-17 | 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 | 2022-08-17 | 2022-09-17 | Y |
| Post nurse staffing information every day. | Health | 2022-08-17 | 2022-09-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-17 | 2022-09-17 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-22 | 2022-04-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-22 | 2022-04-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-22 | 2022-04-27 | 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 | 2022-02-25 | 2022-04-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-25 | 2022-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-25 | 2022-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-25 | 2022-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-04-01 | 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 | 2022-02-25 | 2022-04-01 | N |
| Provide or obtain dental services for each resident. | Health | 2022-02-25 | 2022-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-04-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-18 | 2021-10-13 | 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 | 2021-09-18 | 2021-10-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-18 | 2021-10-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-18 | 2021-10-13 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-09 | 2021-05-08 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-09 | 2020-01-25 | 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 | 2019-12-09 | 2020-01-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-09 | 2020-01-25 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-12-11 | 2020-01-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-11 | 2020-01-04 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-11 | 2020-01-04 | 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 | 2019-12-11 | 2020-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-11 | 2020-01-04 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-02-06 | 2019-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-06 | 2019-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-06 | 2019-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-06 | 2019-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-04 | 2019-03-15 | N |
