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Deficiency Records for Hammonds Lane Center
A list of the most recent deficiencies for Hammonds Lane 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 Hammonds Lane 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-20 | 2023-08-30 | 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 | 2023-06-20 | 2023-08-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-20 | 2023-08-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-20 | 2023-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-20 | 2023-08-30 | Y |
| 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 | 2023-06-20 | 2023-08-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-20 | 2023-08-30 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-19 | 2023-08-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-20 | 2023-08-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-20 | 2023-08-04 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-20 | 2023-08-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-20 | 2023-08-04 | 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 | 2023-06-20 | 2023-08-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-20 | 2023-08-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-20 | 2023-08-04 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-06-20 | 2023-08-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-20 | 2023-08-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-20 | 2023-08-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-20 | 2023-08-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-20 | 2023-08-04 | Y |
| 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 | 2023-06-20 | 2023-08-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-20 | 2023-08-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-20 | 2023-08-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-20 | 2023-08-04 | Y |
| Meet other general requirements. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-19 | 2023-07-31 | 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 | 2023-05-19 | 2023-07-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-19 | 2023-07-31 | 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 | 2023-05-19 | 2023-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-19 | 2023-07-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-17 | 2019-02-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-01-17 | 2019-02-28 | N |
| 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 | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-17 | 2019-02-28 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2019-01-17 | 2019-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-17 | 2019-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-17 | 2019-02-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-01-17 | 2019-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-17 | 2019-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-17 | 2019-02-28 | N |
| Dispose of garbage and refuse properly. | Health | 2019-01-17 | 2019-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-17 | 2019-02-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-01-17 | 2019-02-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-01-17 | 2019-02-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-20 | 2019-01-31 | 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 | 2018-12-20 | 2019-01-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-12-20 | 2019-01-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-20 | 2019-01-31 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-09-01 | 2017-10-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-01 | 2017-10-13 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-09-01 | 2017-10-13 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-01 | 2017-10-13 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-01 | 2017-10-13 | N |
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