Kirkwood Manor

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Resident Rights Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Provide training in compliance and ethics.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

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.

Administration Deficiencies

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.