A list of the most recent deficiencies for Beach Creek Post-Acute. 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 safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-23 | 2024-02-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-24 | 2023-08-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-03 | 2023-05-03 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-07 | 2023-04-06 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-03-07 | 2023-04-06 | 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 | 2023-03-07 | 2023-04-06 | 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 | 2023-03-07 | 2023-04-06 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-07 | 2023-04-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-07 | 2023-04-06 | 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 | 2023-03-07 | 2023-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-07 | 2023-04-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-07 | 2023-04-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-07 | 2023-04-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-07 | 2023-04-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-07 | 2023-04-06 | 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 | 2023-03-07 | 2023-04-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-07 | 2023-04-06 | 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 | 2023-03-07 | 2023-04-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-07 | 2023-04-06 | 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 | 2023-03-07 | 2023-04-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-07 | 2023-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-07 | 2023-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-07 | 2023-04-06 | N |
| 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 | 2023-03-07 | 2023-04-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-17 | 2023-03-16 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-06 | 2023-03-08 | 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 | 2023-03-06 | 2023-03-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-06 | 2023-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-06 | 2023-03-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-23 | 2021-12-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-07 | 2021-11-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-10 | 2021-09-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-10 | 2021-09-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-14 | 2021-04-26 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-10-16 | 2019-11-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-16 | 2019-11-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-16 | 2019-11-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-10-16 | 2019-11-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-24 | 2019-10-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-24 | 2019-10-23 | N |
| 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 | 2019-09-24 | 2019-10-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-24 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-24 | 2019-10-23 | N |
| Develop a communication plan. | Fire Safety | 2018-11-26 | 2018-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-26 | 2018-12-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-10-03 | 2018-11-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-03 | 2018-11-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-03 | 2018-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-03 | 2018-11-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-03 | 2018-11-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-03 | 2018-11-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-03 | 2018-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-03 | 2018-11-01 | N |
