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Deficiency Records for Episcopal Church Home of Minnesota
A list of the most recent deficiencies for Episcopal Church Home of Minnesota. 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 Episcopal Church Home of Minnesota. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-29 | 2024-06-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-29 | 2024-06-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-29 | 2024-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-29 | 2024-06-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-29 | 2024-06-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-25 | 2024-02-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-25 | 2024-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-26 | 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 | 2024-01-25 | 2024-02-26 | 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 | 2024-01-25 | 2024-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-02-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-25 | 2024-02-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-25 | 2024-02-26 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-25 | 2024-02-26 | 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 | 2024-01-23 | 2024-02-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-23 | 2024-02-26 | 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 | 2024-01-23 | 2024-02-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-13 | 2023-08-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-25 | 2023-03-24 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-25 | 2023-03-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-09 | 2023-01-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-21 | 2022-12-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-20 | 2022-12-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-20 | 2022-12-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-20 | 2022-12-23 | 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 | 2022-10-20 | 2022-12-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-20 | 2022-12-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-20 | 2022-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-12-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-18 | 2022-12-23 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-10-18 | 2022-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-20 | 2022-05-28 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-17 | 2022-03-29 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-08 | 2021-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-08 | 2021-08-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-10 | 2021-07-29 | 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 | 2021-06-10 | 2021-07-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-07-29 | 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 | 2021-06-10 | 2021-07-29 | 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 | 2021-06-10 | 2021-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-10 | 2021-07-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-08 | 2021-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-08 | 2021-07-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-08 | 2021-07-01 | N |
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