A list of the most recent deficiencies for Complete Care at Dawnview 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-10 | 2023-03-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-10 | 2023-03-02 | 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 | 2023-01-10 | 2023-03-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-10 | 2023-03-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-10 | 2023-03-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-10 | 2023-03-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-10 | 2023-03-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-10 | 2023-03-02 | 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 | 2023-01-10 | 2023-03-02 | 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 | 2023-01-10 | 2023-03-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-10 | 2023-03-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-10 | 2023-03-02 | 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 | 2023-01-10 | 2023-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-10 | 2023-03-02 | N |
| Keep all essential equipment working safely. | Health | 2023-01-10 | 2023-03-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-16 | 2022-09-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-16 | 2022-09-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-15 | 2021-11-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-15 | 2021-11-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-15 | 2021-11-12 | 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 | 2021-09-15 | 2021-11-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-15 | 2021-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-15 | 2021-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-15 | 2021-11-12 | 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 | 2021-09-15 | 2021-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-15 | 2021-11-12 | N |
| Post nurse staffing information every day. | Health | 2021-09-15 | 2021-11-12 | 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 | 2021-09-15 | 2021-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-11-12 | N |
| Keep all essential equipment working safely. | Health | 2021-09-15 | 2021-11-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-15 | 2021-11-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-06 | 2019-08-15 | 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 | 2019-06-06 | 2019-08-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-06 | 2019-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-06 | 2019-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-06 | 2019-08-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-06-06 | 2019-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-08-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-06 | 2019-08-15 | 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 | 2019-06-06 | 2019-08-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-06-06 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-08-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-06 | 2019-08-15 | N |
