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Deficiency Records for Steubenville Country Club Manor
A list of the most recent deficiencies for Steubenville Country Club Manor. 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 Steubenville Country Club Manor. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-30 | 2024-07-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-30 | 2024-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-30 | 2024-07-12 | Y |
| 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 | 2024-05-30 | 2024-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-30 | 2024-07-12 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-05-30 | 2024-07-12 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-30 | 2024-07-12 | Y |
| 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 | 2024-05-30 | 2024-07-12 | 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 | 2024-05-30 | 2024-07-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-30 | 2024-07-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-30 | 2024-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-30 | 2024-07-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-05-30 | 2024-07-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-15 | 2024-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-15 | 2024-04-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-15 | 2024-04-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-15 | 2024-04-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-15 | 2024-04-19 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-21 | 2023-10-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-02 | 2023-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-07 | 2023-10-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-07 | 2023-10-12 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-21 | 2023-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-09-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-21 | 2023-09-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-21 | 2023-09-05 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-07-21 | 2023-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-07 | 2023-09-05 | 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 | 2023-07-07 | 2023-09-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-07 | 2023-09-05 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-07 | 2023-09-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-07 | 2023-09-05 | Y |
| 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 | 2023-07-07 | 2023-09-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-07 | 2023-09-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-07 | 2023-09-05 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-07-07 | 2023-09-05 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-07 | 2023-09-05 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-07-07 | 2023-09-05 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-07-07 | 2023-09-05 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-07 | 2023-09-05 | Y |
| Provide training in compliance and ethics. | Health | 2023-07-07 | 2023-09-05 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-07 | 2023-09-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-04 | 2023-05-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-04 | 2023-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-04 | 2023-05-19 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-04 | 2023-05-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-06 | 2023-01-27 | Y |
| 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 | 2022-09-12 | 2022-10-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-12 | 2022-10-31 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-09-12 | 2022-10-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-12 | 2022-10-31 | 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 | 2022-09-12 | 2022-10-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-12 | 2022-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-12 | 2022-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-12 | 2022-10-31 | 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 | 2022-09-12 | 2022-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-12 | 2022-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-12 | 2022-10-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-12 | 2022-10-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-12 | 2022-10-31 | 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 | 2022-09-12 | 2022-10-31 | 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 | 2022-09-12 | 2022-10-31 | 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 | 2022-09-12 | 2022-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-12 | 2022-10-31 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-09-12 | 2022-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-12 | 2022-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-06 | 2022-10-31 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-06 | 2022-10-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-06 | 2022-10-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-27 | 2020-03-14 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-27 | 2020-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-27 | 2020-03-14 | 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 | 2019-11-27 | 2020-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-27 | 2020-03-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-26 | 2020-03-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-26 | 2020-03-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-26 | 2020-03-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-26 | 2020-03-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-26 | 2020-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-26 | 2020-03-14 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-26 | 2020-02-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-11-26 | 2020-02-07 | 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 | 2019-11-27 | 2020-02-06 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-27 | 2020-02-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-27 | 2020-02-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-27 | 2020-02-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-27 | 2020-02-06 | 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 | 2019-11-27 | 2020-02-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-27 | 2018-11-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-27 | 2018-11-09 | 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 | 2018-09-27 | 2018-11-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-27 | 2018-11-09 | 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 | 2018-09-27 | 2018-11-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-27 | 2018-11-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-27 | 2018-11-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-27 | 2018-11-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-27 | 2018-11-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-27 | 2018-11-09 | 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 | 2018-09-27 | 2018-11-09 | 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 | 2018-09-27 | 2018-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-27 | 2018-11-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-27 | 2018-11-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
| Develop a communication plan. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-26 | 2018-11-09 | N |
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