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Deficiency Records for Blaire House of Tewksbury
A list of the most recent deficiencies for Blaire House of Tewksbury. 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 Blaire House of Tewksbury. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-11-14 | 2025-01-21 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-11-14 | 2024-12-29 | 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 | 2024-11-14 | 2024-12-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-11-14 | 2024-12-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-10-23 | 2024-12-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-10-23 | 2024-12-07 | 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 | 2024-10-23 | 2024-12-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-10-23 | 2024-12-07 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-10-23 | 2024-12-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-23 | 2024-12-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-23 | 2024-12-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-23 | 2024-12-07 | 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 | 2024-10-23 | 2024-12-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-23 | 2024-12-07 | 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 | 2024-10-23 | 2024-12-07 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-10-23 | 2024-12-07 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-10-23 | 2024-12-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-10-23 | 2024-12-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-10-23 | 2024-12-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-10-23 | 2024-12-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-17 | 2023-12-27 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-17 | 2023-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-17 | 2023-12-27 | 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 | 2023-10-17 | 2023-12-27 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-17 | 2023-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-17 | 2023-12-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-17 | 2023-11-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-17 | 2023-11-17 | 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 | 2023-10-17 | 2023-11-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-17 | 2023-11-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-17 | 2023-11-17 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-17 | 2023-11-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-17 | 2023-11-17 | 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 | 2023-10-17 | 2023-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-17 | 2023-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-17 | 2023-11-17 | 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 | 2023-10-17 | 2023-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-17 | 2023-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-17 | 2023-11-17 | 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 | 2023-10-17 | 2023-11-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-17 | 2023-11-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-17 | 2023-11-17 | 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 | 2023-10-17 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-17 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-17 | 2023-11-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-28 | 2023-11-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-09-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-09-28 | 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 | 2022-09-01 | 2022-09-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-01 | 2022-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-09-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-01 | 2022-09-28 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-01 | 2022-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-01 | 2022-09-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-01 | 2022-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-09-17 | N |
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