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Deficiency Records for Phoenix of Maple Heights
A list of the most recent deficiencies for Phoenix of Maple Heights. 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 Phoenix of Maple Heights. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-10 | 2024-08-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-06-13 | 2024-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-13 | 2024-08-13 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-06-13 | 2024-08-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-13 | 2024-08-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-06-13 | 2024-08-13 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-06-13 | 2024-08-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-13 | 2024-08-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-06-13 | 2024-08-13 | 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 | 2024-06-13 | 2024-08-13 | 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 | 2024-06-13 | 2024-08-13 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-06-13 | 2024-08-13 | 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 | 2024-06-13 | 2024-08-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-06-13 | 2024-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-13 | 2024-08-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-06-13 | 2024-08-13 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-06-13 | 2024-08-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-06-13 | 2024-08-13 | 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 | 2024-06-13 | 2024-08-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-13 | 2024-08-13 | Y |
| 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 | 2024-06-13 | 2024-08-13 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-10 | 2024-08-12 | 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 | 2024-06-10 | 2024-08-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-10 | 2024-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-30 | 2024-05-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-27 | 2024-04-12 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-30 | 2023-12-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2023-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-01 | 2023-02-20 | Y |
| 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 | 2023-01-03 | 2023-02-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-03 | 2023-02-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-03 | 2023-02-20 | Y |
| Keep all essential equipment working safely. | Health | 2023-01-03 | 2023-02-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-03 | 2023-02-20 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-03 | 2023-02-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-13 | 2022-11-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-13 | 2022-11-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-28 | 2022-06-06 | 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 | 2022-04-28 | 2022-06-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-28 | 2022-06-06 | 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 | 2022-04-28 | 2022-06-06 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2022-04-28 | 2022-06-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-28 | 2022-06-06 | 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 | 2022-04-28 | 2022-06-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-06-06 | 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 | 2022-04-28 | 2022-06-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-28 | 2022-06-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-20 | 2021-11-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-20 | 2021-11-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-28 | 2019-04-16 | 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 | 2019-03-28 | 2019-04-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-28 | 2019-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-28 | 2019-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-28 | 2019-04-16 | 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 | 2019-03-28 | 2019-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-28 | 2019-04-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-28 | 2019-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-28 | 2019-04-16 | 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 | 2019-03-28 | 2019-04-16 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-03-28 | 2019-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-28 | 2019-04-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-28 | 2019-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-28 | 2019-04-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-28 | 2019-04-16 | 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 | 2019-03-27 | 2019-04-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-27 | 2019-04-16 | 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 | 2019-03-27 | 2019-04-16 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-27 | 2019-04-16 | N |
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