A list of the most recent deficiencies for Country Hills 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2024-01-24 | 2024-02-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-24 | 2024-02-12 | Y |
| 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 | 2023-10-19 | 2023-11-29 | Y |
| 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 | 2023-06-08 | 2023-07-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-12 | 2023-05-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-09 | 2023-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-05 | 2023-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-11 | 2022-06-10 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-21 | 2022-06-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-21 | 2022-06-06 | N |
| Provide activities to meet all resident's needs. | Health | 2022-04-21 | 2022-06-06 | 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 | 2022-04-21 | 2022-06-06 | 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 | 2022-04-21 | 2022-06-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-21 | 2022-06-06 | 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 | 2022-04-21 | 2022-06-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-21 | 2022-06-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-21 | 2022-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-21 | 2022-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-06-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-25 | 2022-05-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-25 | 2022-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-25 | 2022-05-24 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-04-25 | 2022-05-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-25 | 2022-05-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-25 | 2022-05-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-26 | 2022-02-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-19 | 2022-02-04 | 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 | 2021-12-16 | 2022-01-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-13 | 2021-09-13 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-05-26 | 2021-06-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-26 | 2021-06-15 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-26 | 2021-06-15 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2021-05-26 | 2021-06-15 | 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 | 2020-01-09 | 2020-03-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-09 | 2020-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-03-03 | 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 | 2020-01-09 | 2020-03-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-09 | 2020-03-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-09 | 2020-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-03-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-01-09 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-29 | 2020-02-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-29 | 2020-02-26 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2020-01-29 | 2020-02-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| 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 | 2019-03-12 | 2019-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-12-13 | 2019-01-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-13 | 2019-01-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-13 | 2019-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-13 | 2019-01-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-13 | 2019-01-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-13 | 2019-01-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-13 | 2019-01-30 | 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 | 2018-12-13 | 2019-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-13 | 2019-01-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-12-13 | 2019-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-13 | 2019-01-30 | N |
| Keep all essential equipment working safely. | Health | 2018-12-13 | 2019-01-30 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2018-12-13 | 2019-01-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-12-13 | 2019-01-30 | N |
