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Deficiency Records for Douglas County Health Center
A list of the most recent deficiencies for Douglas County Health 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 Douglas County Health 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-18 | 2024-07-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-16 | 2024-06-14 | Y |
| 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 | 2024-04-25 | 2024-06-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-04-25 | 2024-06-13 | 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 | 2024-04-25 | 2024-06-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-25 | 2024-06-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-25 | 2024-06-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-04-25 | 2024-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-25 | 2024-06-13 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2024-04-25 | 2024-06-13 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-04-26 | 2024-06-09 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-04-26 | 2024-06-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-26 | 2024-06-09 | 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 | 2024-04-26 | 2024-06-09 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-04-26 | 2024-06-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-26 | 2024-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-26 | 2024-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-26 | 2024-06-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-05 | 2024-03-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-16 | 2023-06-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-16 | 2023-06-29 | N |
| Provide or obtain dental services for each resident. | Health | 2023-05-16 | 2023-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-16 | 2023-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-16 | 2023-06-29 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-05-16 | 2023-06-29 | Y |
| 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 | 2023-05-16 | 2023-06-29 | 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 | 2023-05-16 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-16 | 2023-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-29 | 2022-12-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-06 | 2022-05-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-01 | 2022-05-20 | 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 | 2022-02-01 | 2022-04-27 | 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 | 2022-02-01 | 2022-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-01 | 2022-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-01 | 2022-04-27 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-02-01 | 2022-04-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-01 | 2022-04-27 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-02-01 | 2022-03-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-01 | 2022-03-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-01 | 2022-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-01 | 2022-03-17 | 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 | 2022-02-01 | 2022-03-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-01 | 2022-03-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-01 | 2022-03-17 | 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 | 2022-02-01 | 2022-03-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-01 | 2022-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-03-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-01 | 2022-02-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-01 | 2022-02-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-01 | 2022-02-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-01 | 2022-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-01 | 2022-02-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-01 | 2022-02-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-01 | 2022-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-01 | 2022-02-13 | N |
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