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Deficiency Records for Surrey Place St Lukes Hosp Skilled Nursing
A list of the most recent deficiencies for Surrey Place St Lukes Hosp Skilled Nursing. 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 Surrey Place St Lukes Hosp Skilled Nursing. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-01 | 2024-09-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-01 | 2024-09-06 | 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 | 2024-08-01 | 2024-09-06 | N |
| Post nurse staffing information every day. | Health | 2024-08-01 | 2024-09-06 | 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 | 2024-08-01 | 2024-09-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-01 | 2024-09-06 | 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 | 2024-08-01 | 2024-09-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-08-01 | 2024-09-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-09-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-08-01 | 2024-09-06 | 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 | 2024-08-01 | 2024-09-06 | N |
| Have an externally vented heating system. | Fire Safety | 2024-08-01 | 2024-09-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-01 | 2024-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-01 | 2024-08-23 | 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 | 2024-08-01 | 2024-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-01 | 2024-08-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-01 | 2024-08-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-08-01 | 2024-07-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-28 | 2023-02-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-21 | 2023-02-03 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-22 | 2019-09-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-22 | 2019-08-22 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2019-08-22 | 2019-08-22 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2019-08-22 | 2019-08-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-01 | Not Fixed | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-08-01 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-01 | Not Fixed | N |
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