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Deficiency Records for Hannah Duston Healthcare Center
A list of the most recent deficiencies for Hannah Duston 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 Hannah Duston 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-30 | 2024-07-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-30 | 2024-07-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-30 | 2024-07-14 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-30 | 2024-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-30 | 2024-07-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-30 | 2024-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-30 | 2024-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-30 | 2024-07-14 | 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 | 2024-05-30 | 2024-07-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-30 | 2024-07-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-05-30 | 2024-07-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-30 | 2024-07-14 | 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 | 2024-05-30 | 2024-07-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-30 | 2024-07-14 | 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 | 2024-05-30 | 2024-07-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-30 | 2024-07-14 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-05-30 | 2024-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-30 | 2024-07-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-30 | 2024-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-30 | 2024-07-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-30 | 2024-07-14 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-05-30 | 2024-07-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-05-30 | 2024-07-14 | N |
| Ensure that paid feeding assistants have the training they need. | Health | 2024-05-30 | 2024-07-14 | 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 | 2024-05-30 | 2024-06-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-22 | 2023-12-31 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-25 | 2023-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-13 | 2023-05-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-13 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-05-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-05-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-06 | 2023-05-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-06 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-06 | 2023-05-12 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-01 | 2022-05-16 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-04-01 | 2022-05-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-03-14 | 2022-04-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-14 | 2022-04-20 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-14 | 2022-04-20 | 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 | 2022-03-14 | 2022-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide appropriate foot care. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-14 | 2022-04-20 | 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 | 2022-03-14 | 2022-04-20 | N |
| Provide or obtain dental services for each resident. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-14 | 2022-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-14 | 2022-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-14 | 2022-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-14 | 2022-04-08 | N |
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