A list of the most recent deficiencies for The Enclave. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-29 | 2024-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-29 | 2024-01-30 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-19 | 2023-04-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-19 | 2023-04-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-19 | 2023-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-19 | 2023-04-27 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-04-19 | 2023-04-27 | 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 | 2023-03-24 | 2023-04-21 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-19 | 2022-12-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-19 | 2022-12-20 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-12-19 | 2022-12-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-19 | 2022-12-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-15 | 2022-11-16 | 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 | 2022-03-04 | 2022-03-05 | 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 | 2022-03-04 | 2022-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-03-05 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-04 | 2022-03-05 | 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 | 2022-01-07 | 2022-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-28 | 2022-01-19 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-25 | 2021-10-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-31 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-31 | 2021-09-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-08 | 2021-04-10 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-12-01 | 2021-01-12 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-12-04 | 2020-12-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-12-04 | 2020-12-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-12-04 | 2020-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-12-04 | 2020-12-22 | 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 | 2020-12-04 | 2020-12-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-12-04 | 2020-12-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-12-04 | 2020-12-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-12-04 | 2020-12-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-12-04 | 2020-12-22 | N |
| Dispose of garbage and refuse properly. | Health | 2020-12-04 | 2020-12-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-12-04 | 2020-12-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-12-01 | 2020-12-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-12-01 | 2020-12-07 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-12-01 | 2020-12-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2020-12-01 | 2020-12-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-12-01 | 2020-12-07 | N |
