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Deficiency Records for Pershing General Hospital Snf
A list of the most recent deficiencies for Pershing General Hospital Snf. 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 Pershing General Hospital Snf. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-15 | 2024-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-15 | 2024-05-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-15 | 2024-05-17 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-15 | 2024-05-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-15 | 2024-05-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-04-15 | 2024-05-17 | N |
| Provide or obtain dental services for each resident. | Health | 2024-04-15 | 2024-05-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-04-15 | 2024-05-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-04-15 | 2024-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-15 | 2024-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-15 | 2024-05-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-15 | 2024-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-15 | 2024-05-15 | 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 | 2024-04-15 | 2024-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-15 | 2024-05-15 | Y |
| 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 | 2024-04-15 | 2024-05-13 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-04-15 | 2024-05-13 | 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 | 2024-04-15 | 2024-04-23 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-04-15 | 2024-04-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-15 | 2024-04-20 | 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 | 2024-04-15 | 2024-04-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-28 | 2024-03-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-28 | 2024-03-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-28 | 2024-03-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-28 | 2024-03-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-28 | 2024-03-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-19 | 2023-10-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-19 | 2023-10-23 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-19 | 2023-10-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-19 | 2023-10-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-19 | 2023-10-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-19 | 2023-10-19 | 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 | 2023-10-19 | 2023-10-19 | 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 | 2023-10-19 | 2023-10-19 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-19 | 2023-10-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-19 | 2023-10-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-10-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-19 | 2023-10-19 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-19 | 2023-10-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-19 | 2023-10-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-19 | 2023-10-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-20 | 2023-06-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-20 | 2023-06-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-20 | 2023-06-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-04-20 | 2023-06-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-20 | 2023-06-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-20 | 2023-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-20 | 2023-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-06-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-20 | 2023-06-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-20 | 2023-06-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-04-20 | 2023-06-05 | 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 | 2023-04-20 | 2023-06-05 | 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 | 2023-04-20 | 2023-06-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-04-20 | 2023-06-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-20 | 2023-06-05 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-20 | 2023-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-20 | 2023-06-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-04-20 | 2023-06-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-20 | 2023-06-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-04-20 | 2023-06-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-20 | 2023-06-05 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-20 | 2023-06-05 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-04-20 | 2023-06-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-20 | 2023-06-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-04-20 | 2023-06-02 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-04-20 | 2023-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-21 | 2023-05-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-21 | 2023-05-30 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-04-20 | 2023-05-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-13 | 2022-12-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-12-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-07 | 2021-11-22 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-07 | 2021-11-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-11-16 | 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 | 2021-10-07 | 2021-11-16 | Y |
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