A list of the most recent deficiencies for Kirkwood Manor. 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? |
|---|---|---|---|---|
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-01-26 | 2024-03-08 | N |
| Provide training in compliance and ethics. | Health | 2024-01-26 | 2024-03-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-26 | 2024-02-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-02-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-26 | 2024-02-29 | 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 | 2024-01-26 | 2024-02-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-26 | 2024-02-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-26 | 2024-02-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-26 | 2024-02-16 | 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 | 2024-01-26 | 2024-02-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-26 | 2024-02-14 | 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 | 2024-01-26 | 2024-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-26 | 2024-02-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-26 | 2024-02-06 | 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 | 2024-01-26 | 2024-02-02 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-01-26 | 2024-02-02 | 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 | 2024-01-26 | 2024-02-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-26 | 2024-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-26 | 2024-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-26 | 2024-01-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-30 | 2023-12-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-30 | 2023-12-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-16 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-11-09 | 2022-11-30 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-08 | 2022-11-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-09 | 2022-11-11 | 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 | 2022-11-09 | 2022-11-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-09 | 2022-11-11 | 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 | 2022-11-09 | 2022-11-10 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-11-09 | 2022-11-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-09 | 2022-11-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-09 | 2022-11-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-09 | 2022-11-10 | 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 | 2022-11-09 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-09 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-09 | 2022-11-10 | 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 | 2022-11-09 | 2022-11-10 | Y |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2021-10-07 | 2021-11-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-05 | 2021-10-29 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-10-05 | 2021-10-08 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-07 | 2021-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-30 | 2021-08-27 | Y |
