A list of the most recent deficiencies for Retama Manor Nursing Center. 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-16 | 2023-12-16 | Y |
| 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 | 2023-10-19 | 2023-10-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-23 | 2023-08-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-23 | 2023-07-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-23 | 2023-07-25 | Y |
| 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 | 2023-05-19 | 2023-05-20 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-22 | 2023-04-05 | 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 | 2022-01-14 | 2022-03-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-14 | 2022-03-03 | 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 | 2022-01-14 | 2022-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-03-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-01-14 | 2022-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-12 | 2022-02-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-12 | 2022-02-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-23 | 2020-11-23 | 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 | 2020-10-23 | 2020-11-23 | 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 | 2020-10-23 | 2020-11-23 | 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 | 2020-10-23 | 2020-11-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-23 | 2020-11-23 | 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 | 2020-10-23 | 2020-11-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-23 | 2020-11-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-10-23 | 2020-11-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-10-23 | 2020-11-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-10-23 | 2020-11-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-10-22 | 2020-10-23 | 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 | 2020-10-22 | 2020-10-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-22 | 2020-10-23 | N |
