A list of the most recent deficiencies for The Waterton at Cowhorn Creek. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-02-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-07 | 2024-02-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-07 | 2024-02-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-16 | 2023-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2023-11-22 | 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 | 2023-11-16 | 2023-11-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2023-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2023-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-16 | 2023-11-17 | 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 | 2023-11-16 | 2023-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-16 | 2023-11-17 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-11-16 | 2023-11-17 | 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 | 2023-11-16 | 2023-11-17 | 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 | 2023-11-16 | 2023-11-17 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-11-16 | 2023-11-17 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-11-16 | 2023-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-11-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-12 | 2022-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-12 | 2022-10-24 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-12 | 2022-10-24 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-10-12 | 2022-10-24 | 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 | 2022-10-12 | 2022-10-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-12 | 2022-10-24 | 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 | 2022-10-12 | 2022-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-12 | 2022-10-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-12 | 2022-10-24 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-16 | 2022-03-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-16 | 2022-03-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-06 | 2021-08-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-06 | 2021-08-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-05 | 2021-08-18 | N |
