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Deficiency Records for Country Manor Healthcare
A list of the most recent deficiencies for Country Manor Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Country Manor Healthcare. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-28 | 2024-06-25 | Y |
| 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 | 2024-05-28 | 2024-06-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-27 | 2023-12-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-27 | 2023-12-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-03 | 2023-11-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-03 | 2023-11-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-03 | 2023-11-30 | 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 | 2023-11-03 | 2023-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2023-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-03 | 2023-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-03 | 2023-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-03 | 2023-11-30 | 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 | 2023-11-03 | 2023-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-03 | 2023-11-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-11-03 | 2023-11-30 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-11-03 | 2023-11-30 | 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 | 2023-11-03 | 2023-11-30 | 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 | 2023-11-03 | 2023-11-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-03 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-03 | 2023-11-30 | N |
| Keep all essential equipment working safely. | Health | 2023-11-03 | 2023-11-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-11-01 | 2023-11-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-01 | 2023-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-11-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-30 | 2023-09-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-17 | 2023-09-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-10 | 2022-12-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-10 | 2022-12-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-10 | 2022-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-10 | 2022-12-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-17 | 2022-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-22 | 2022-08-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-08-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-24 | 2022-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-24 | 2022-08-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-24 | 2022-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-24 | 2022-07-24 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-11-20 | 2019-12-20 | N |
| Establish methods for sharing information. | Fire Safety | 2019-11-20 | 2019-12-20 | 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 | 2019-11-20 | 2019-12-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-20 | 2019-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-20 | 2019-12-20 | N |
| Meet other general requirements. | Fire Safety | 2019-11-20 | 2019-12-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-17 | 2019-12-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-17 | 2019-12-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-11-17 | 2019-12-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-17 | 2019-12-17 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-11-17 | 2019-12-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-17 | 2019-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-17 | 2019-12-17 | N |
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