A list of the most recent deficiencies for Community Care On Palm. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-04 | 2024-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-04 | 2024-01-14 | Y |
| 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 | 2024-01-04 | 2024-01-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-12-01 | 2023-12-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-28 | 2023-12-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-18 | 2023-06-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-18 | 2023-06-03 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-05-18 | 2023-06-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-05-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-17 | 2023-04-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2022-12-09 | Y |
| 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 | 2022-08-17 | 2022-08-29 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-18 | 2022-03-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-18 | 2022-03-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-02-18 | 2022-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-18 | 2022-03-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-03-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-18 | 2022-03-23 | 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 | 2022-02-18 | 2022-03-23 | 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 | 2022-02-18 | 2022-03-23 | 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 | 2022-02-18 | 2022-03-23 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-18 | 2022-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-18 | 2022-03-23 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-02-18 | 2022-03-23 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-18 | 2022-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-23 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-08 | 2022-03-22 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-02-22 | 2022-03-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-22 | 2022-03-08 | 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 | 2022-02-22 | 2022-03-08 | 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 | 2022-02-22 | 2022-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-22 | 2022-03-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-01-18 | 2022-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-20 | 2022-02-03 | 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 | 2021-12-20 | 2022-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-20 | 2022-02-03 | Y |
| 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 | 2021-12-20 | 2022-02-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-20 | 2022-02-03 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-20 | 2022-02-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-07 | 2021-12-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-07 | 2021-12-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-07 | 2021-12-27 | 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 | 2021-10-04 | 2021-11-01 | 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 | 2021-07-13 | 2021-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-13 | 2021-08-11 | Y |
| 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 | 2021-07-13 | 2021-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-13 | 2021-08-11 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-30 | 2020-01-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-30 | 2020-01-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-30 | 2020-01-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-19 | 2020-01-09 | 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 | 2019-12-19 | 2020-01-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-19 | 2020-01-09 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-12-19 | 2020-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-19 | 2020-01-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-19 | 2020-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-09 | 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 | 2019-12-19 | 2020-01-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-19 | 2020-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-19 | 2020-01-08 | N |
| Dispose of garbage and refuse properly. | Health | 2019-12-19 | 2020-01-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-11 | 2019-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-11 | 2019-02-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-11 | 2019-02-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-14 | 2019-01-14 | 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 | 2018-12-14 | 2019-01-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-12-14 | 2019-01-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-12-14 | 2019-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-14 | 2019-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-14 | 2019-01-14 | 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 | 2018-12-14 | 2019-01-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-14 | 2019-01-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-14 | 2019-01-14 | 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 | 2018-12-14 | 2019-01-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-14 | 2019-01-14 | 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 | 2018-12-14 | 2019-01-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-14 | 2019-01-14 | 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 | 2018-12-14 | 2019-01-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-14 | 2019-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-14 | 2019-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-14 | 2019-01-14 | N |
