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Deficiency Records for Spring Hill Manor
A list of the most recent deficiencies for Spring Hill Manor. 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 Spring Hill Manor. 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? |
|---|---|---|---|---|
| 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 | 2023-06-09 | 2023-06-30 | 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 | 2023-06-09 | 2023-06-30 | 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 | 2023-06-09 | 2023-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-09 | 2023-06-30 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-06-09 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-14 | 2023-06-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-14 | 2023-06-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-14 | 2023-06-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-14 | 2023-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-14 | 2023-06-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-14 | 2023-06-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-24 | 2023-04-11 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-01-27 | 2022-02-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-11 | 2019-11-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-11 | 2019-11-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Use approved construction type or materials. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-13 | 2019-01-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-01 | 2018-12-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-11-01 | 2018-12-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-01 | 2018-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-01 | 2018-12-20 | N |
| Dispose of garbage and refuse properly. | Health | 2018-11-01 | 2018-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-01 | 2018-12-20 | N |
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