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Deficiency Records for Memorial Hospital Ltcu (village Manor)
A list of the most recent deficiencies for Memorial Hospital Ltcu (village 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 Memorial Hospital Ltcu (village 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-07 | 2024-10-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-07 | 2024-10-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-10-07 | 2024-10-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-10-07 | 2024-10-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-07 | 2024-10-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-07 | 2024-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-06-29 | Y |
| 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 | 2023-03-15 | 2023-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Meet other general requirements. | Fire Safety | 2023-03-15 | 2023-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-15 | 2023-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-20 | 2023-03-08 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-08 | 2023-03-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-08 | Y |
| 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 | 2023-02-08 | 2023-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-25 | 2022-08-05 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-09 | 2021-10-13 | 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 | 2021-09-09 | 2021-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-09 | 2021-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-09 | 2021-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-09 | 2021-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-08-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-09-11 | Not Fixed | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-09-11 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-11 | Not Fixed | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-11 | Not Fixed | 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 | 2024-09-11 | Not Fixed | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-09-11 | Not Fixed | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-09-11 | Not Fixed | 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 | 2024-09-11 | Not Fixed | 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 | 2024-09-11 | Not Fixed | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-09-11 | Not Fixed | N |
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