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Deficiency Records for Evangelical Home - Saline
A list of the most recent deficiencies for Evangelical Home - Saline. 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 Evangelical Home - Saline. 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? |
---|---|---|---|---|
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 | 2024-11-19 | 2025-01-16 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-11-19 | 2025-01-16 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-22 | 2024-12-27 | 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 | 2024-11-22 | 2024-12-27 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-11-22 | 2024-12-27 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-22 | 2024-12-27 | 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 | 2024-11-22 | 2024-12-27 | 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 | 2024-11-22 | 2024-12-27 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2024-11-22 | 2024-12-27 | 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 | 2024-11-22 | 2024-12-27 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-22 | 2024-12-27 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-11-22 | 2024-12-27 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-11-22 | 2024-12-27 | Y |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-13 | 2023-10-13 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-13 | 2023-10-13 | N |
Respond appropriately to all alleged violations. | Health | 2023-09-13 | 2023-10-13 | 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 | 2023-09-13 | 2023-10-13 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-13 | 2023-10-13 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-13 | 2023-10-13 | 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 | 2023-09-13 | 2023-10-13 | 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 | 2023-09-13 | 2023-10-13 | 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 | 2023-09-13 | 2023-10-13 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-13 | 2023-10-13 | N |
Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-13 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-13 | 2023-10-13 | 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 | 2023-09-12 | 2023-10-13 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-27 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-07-27 | Y |
Respond appropriately to all alleged violations. | Health | 2023-06-29 | 2023-07-27 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-07-27 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-27 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-02 | 2023-03-28 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-02 | 2023-03-28 | Y |
Respond appropriately to all alleged violations. | Health | 2023-03-02 | 2023-03-28 | Y |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-02 | 2023-03-28 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-02 | 2023-03-28 | 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 | 2023-03-02 | 2023-03-28 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-03-28 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-03-02 | 2023-03-28 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-02 | 2023-03-28 | Y |
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 | 2022-07-26 | 2022-08-24 | 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 | 2022-07-26 | 2022-08-24 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-26 | 2022-08-24 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-26 | 2022-08-24 | 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 | 2022-07-26 | 2022-08-24 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-26 | 2022-08-24 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-26 | 2022-08-24 | 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 | 2022-07-26 | 2022-08-24 | 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 | 2022-07-26 | 2022-08-24 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-26 | 2022-08-24 | N |
Perform COVID19 testing on residents and staff. | Health | 2022-07-26 | 2022-08-24 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-26 | 2022-08-24 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-26 | 2022-08-24 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-26 | 2022-08-24 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-26 | 2022-08-24 | Y |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-21 | 2022-08-24 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-21 | 2022-08-24 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-21 | 2022-08-24 | N |
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