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Deficiency Records for Bancroft Healthcare Center
A list of the most recent deficiencies for Bancroft Healthcare Center. 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 Bancroft Healthcare 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? |
|---|---|---|---|---|
| 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 | 2024-10-10 | 2024-10-31 | N |
| 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 | 2024-10-10 | 2024-10-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-10 | 2024-10-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-10-10 | 2024-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-10-10 | 2024-10-31 | 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 | 2024-10-10 | 2024-10-31 | 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 | 2024-10-10 | 2024-10-31 | 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 | 2024-10-10 | 2024-10-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-10-10 | 2024-10-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Develop a communication plan. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-10-14 | 2024-10-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-14 | 2024-10-28 | 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 | 2023-11-27 | 2023-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-27 | 2023-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-27 | 2023-12-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-27 | 2023-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-27 | 2023-12-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-27 | 2023-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-27 | 2023-12-18 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-11-16 | 2023-12-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-16 | 2023-12-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-16 | 2023-12-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-16 | 2023-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-01 | 2022-05-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-01 | 2022-05-18 | N |
| 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 | 2022-03-01 | 2022-05-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-01 | 2022-05-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-03-01 | 2022-05-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-01 | 2022-05-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-01 | 2022-05-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-01 | 2022-05-18 | 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 | 2022-03-01 | 2022-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-01 | 2022-05-18 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-01 | 2022-05-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-01 | 2022-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-01 | 2022-05-18 | N |
| Keep all essential equipment working safely. | Health | 2022-03-01 | 2022-05-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-01 | 2022-05-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
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