Deficiency Records for Lily Springs Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lily Springs Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-29 | 2023-08-16 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-26 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-13 | 2023-02-18 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-30 | 2022-12-27 | 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 | 2022-11-30 | 2022-12-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-30 | 2022-12-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-30 | 2022-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-30 | 2022-12-27 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-30 | 2022-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-30 | 2022-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-30 | 2022-12-27 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-11-30 | 2022-12-27 | 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 | 2022-02-25 | 2022-02-26 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-09-30 | 2021-10-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-30 | 2021-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-30 | 2021-10-22 | 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 | 2021-09-30 | 2021-10-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-09-30 | 2021-10-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-30 | 2021-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-10-22 | 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 | 2021-09-30 | 2021-10-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-05-07 | 2019-06-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-05-07 | 2019-06-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-07 | 2019-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-09 | 2019-06-24 | N |
