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Deficiency Records for Graham Hospital

A list of the most recent deficiencies for Graham Hospital. 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 Graham Hospital. 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?
Install a two-hour-resistant firewall separation. Fire Safety 2023-12-06 2023-12-18 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2023-12-06 2023-12-18 N
Provide and implement an infection prevention and control program. Health 2023-11-08 2023-11-21 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-02-02 2023-03-02 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-02-02 2023-03-02 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-02-02 2023-03-02 N
Install an approved automatic sprinkler system. Fire Safety 2023-02-02 2023-02-27 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-02-02 2023-02-23 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-02-02 2023-02-23 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 2023-02-02 2023-02-23 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 2023-02-02 2023-02-23 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-03-19 2021-05-10 N
Address patient/client population and determine types of services needed. Fire Safety 2021-03-19 2021-05-10 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2021-03-19 2021-05-10 N
Address subsistence needs for staff and patients. Fire Safety 2021-03-19 2021-05-10 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2021-03-19 2021-05-10 N
Establish policies and procedures including evacuation. Fire Safety 2021-03-19 2021-05-10 N
Establish policies and procedures for sheltering. Fire Safety 2021-03-19 2021-05-10 N
Establish policies and procedures for medical documentation. Fire Safety 2021-03-19 2021-05-10 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-03-19 2021-05-10 N
Develop a communication plan. Fire Safety 2021-03-19 2021-05-10 N
List the names and contact information of those in the facility. Fire Safety 2021-03-19 2021-05-10 N
Provide emergency officials' contact information. Fire Safety 2021-03-19 2021-05-10 N
Establish methods for sharing information. Fire Safety 2021-03-19 2021-05-10 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2021-03-19 2021-05-10 N
Provide family notifications of emergency plan. Fire Safety 2021-03-19 2021-05-10 N
Establish emergency prep training and testing. Fire Safety 2021-03-19 2021-05-10 N
Establish staff and initial training requirements. Fire Safety 2021-03-19 2021-05-10 N
Implement emergency and standby power systems. Fire Safety 2021-03-19 2021-05-10 N
Install a two-hour-resistant firewall separation. Fire Safety 2021-03-19 2021-05-10 N
Conform to length requirements for dead end corridors. Fire Safety 2021-03-19 2021-05-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-03-19 2021-05-10 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-03-19 2021-05-10 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-03-17 2021-05-01 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-03-17 2021-05-01 N

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