A list of the most recent deficiencies for August Healthcare at Leewood. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-24 | 2022-09-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-17 | 2022-04-20 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-17 | 2022-04-20 | N |
| 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 | 2022-03-17 | 2022-04-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-17 | 2022-04-20 | 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 | 2022-03-17 | 2022-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-17 | 2022-04-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-17 | 2022-04-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-17 | 2022-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-20 | 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 | 2022-03-17 | 2022-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-17 | 2022-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-17 | 2022-04-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-17 | 2022-04-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-17 | 2022-04-20 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-17 | 2022-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-17 | 2022-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-06 | 2019-02-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-08 | 2018-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-08 | 2018-11-30 | 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 | 2018-11-08 | 2018-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-08 | 2018-11-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-11-08 | 2018-11-12 | 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 | 2018-11-08 | 2018-11-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-08 | 2018-11-08 | 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 | 2018-11-08 | 2018-11-08 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-11-08 | 2018-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-09-18 | 2017-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-09-18 | 2017-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-09-18 | 2017-12-15 | N |
| Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2017-08-30 | 2017-10-06 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-30 | 2017-10-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-30 | 2017-10-06 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-08-30 | 2017-10-06 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-08-30 | 2017-10-06 | N |
