A list of the most recent deficiencies for Nesbit Living and Recovery 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-24 | 2023-06-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-24 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-24 | 2023-06-16 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-05-05 | 2023-05-12 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-05-05 | 2023-05-12 | 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 | 2023-05-05 | 2023-05-12 | 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 | 2023-05-05 | 2023-05-12 | 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 | 2023-05-05 | 2023-05-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-05 | 2023-05-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-05 | 2023-05-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-05 | 2023-05-12 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-05-05 | 2023-05-12 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-05-05 | 2023-05-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-05 | 2023-05-12 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-05-05 | 2023-05-12 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-05-05 | 2023-05-12 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-05-05 | 2023-05-12 | N |
| Provide training in compliance and ethics. | Health | 2023-05-05 | 2023-05-12 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-05-05 | 2023-05-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-05 | 2023-05-09 | 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 | 2022-10-20 | 2022-11-01 | 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 | 2022-10-04 | 2022-10-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-01 | 2022-08-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-01 | 2022-08-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-19 | 2022-08-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-19 | 2022-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-19 | 2022-08-20 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-03-11 | 2022-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-11 | 2022-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-15 | N |
| Post nurse staffing information every day. | Health | 2022-03-11 | 2022-04-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-11 | 2022-04-08 | 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 | 2022-03-11 | 2022-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-10 | 2022-04-08 | 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 | 2022-03-10 | 2022-04-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-10 | 2022-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-15 | 2021-07-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-25 | 2021-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-25 | 2021-06-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-25 | 2021-06-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-25 | 2021-06-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-26 | 2021-05-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-03-26 | 2021-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-03-26 | 2021-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-26 | 2021-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-26 | 2021-05-17 | N |
