A list of the most recent deficiencies for Professional Post Acute 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-22 | 2023-12-24 | 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 | 2023-11-22 | 2023-12-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-22 | 2023-12-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-22 | 2023-12-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-22 | 2023-12-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-18 | 2023-09-15 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-07-19 | 2023-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-07-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-20 | 2023-05-24 | Y |
| Provide immediate access to any resident. | Health | 2023-04-20 | 2023-05-24 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-04-20 | 2023-05-24 | 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 | 2023-04-20 | 2023-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-20 | 2023-05-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-20 | 2023-05-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-20 | 2023-05-24 | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-04-20 | 2023-05-24 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-05-19 | 2023-05-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-05-23 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-17 | 2023-05-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-01 | 2023-05-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-02-17 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-13 | 2022-12-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-19 | 2022-12-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-19 | 2022-12-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-08 | 2022-11-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-08 | 2022-11-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-08 | 2022-11-08 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-08 | 2022-11-08 | Y |
| Post nurse staffing information every day. | Health | 2022-09-08 | 2022-11-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-08 | 2022-11-08 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-09-08 | 2022-11-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-08 | 2022-11-08 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-09-08 | 2022-11-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-03-03 | 2022-03-28 | 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 | 2021-12-10 | 2022-01-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-07 | 2021-12-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-12-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-19 | 2021-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-19 | 2021-08-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-19 | 2021-08-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-19 | 2021-08-17 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-05-19 | 2021-08-17 | 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 | 2021-05-19 | 2021-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-19 | 2021-08-17 | 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 | 2021-05-19 | 2021-08-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-19 | 2021-08-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-19 | 2021-08-17 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-19 | 2021-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-19 | 2021-08-17 | 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 | 2021-05-19 | 2021-08-17 | 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 | 2021-05-19 | 2021-08-17 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-19 | 2021-08-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-05-19 | 2021-08-17 | N |
| Post nurse staffing information every day. | Health | 2021-05-19 | 2021-08-17 | 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 | 2021-05-19 | 2021-08-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-19 | 2021-08-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-19 | 2021-08-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-19 | 2021-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-08-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-05-19 | 2021-08-17 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-05-06 | 2021-07-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-26 | 2021-06-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-26 | 2021-06-16 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-03-26 | 2021-06-16 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-19 | 2021-06-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-10 | 2021-06-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-14 | 2021-05-27 | 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 | 2021-04-14 | 2021-05-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-21 | 2021-05-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-21 | 2021-05-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-03-29 | 2021-04-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-25 | 2019-07-30 | 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 | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-01 | 2019-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-01 | 2019-06-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-05-01 | 2019-06-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-01 | 2019-06-21 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-01 | 2019-06-21 | 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 | 2019-05-01 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-01 | 2019-06-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-01 | 2019-06-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-01 | 2019-06-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-25 | 2018-08-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-23 | 2018-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-23 | 2018-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-23 | 2018-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-23 | 2018-06-25 | 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 | 2018-05-23 | 2018-06-25 | 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 | 2018-05-23 | 2018-06-25 | 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 | 2018-05-23 | 2018-06-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-23 | 2018-06-25 | N |
