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Deficiency Records for Otterbein Gahanna
A list of the most recent deficiencies for Otterbein Gahanna. 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 Otterbein Gahanna. 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? |
|---|---|---|---|---|
| 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 | 2024-09-18 | 2024-10-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-18 | 2024-10-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-09-18 | 2024-10-18 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2024-09-18 | 2024-10-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-09-18 | 2024-10-18 | N |
| Provide activities to meet all resident's needs. | Health | 2024-09-18 | 2024-10-18 | 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 | 2024-09-18 | 2024-10-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-09-18 | 2024-10-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-09-18 | 2024-10-18 | 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 | 2024-09-18 | 2024-10-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-18 | 2024-10-18 | 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 | 2024-09-18 | 2024-10-18 | 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 | 2024-09-18 | 2024-10-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-09-18 | 2024-10-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-09-18 | 2024-10-18 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-09-18 | 2024-10-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-18 | 2024-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-18 | 2024-10-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-09-18 | 2024-10-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-18 | 2024-10-18 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-09-18 | 2024-10-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-09-18 | 2024-10-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-18 | 2024-10-18 | 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 | 2024-09-18 | 2024-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-18 | 2024-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-18 | 2024-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-18 | 2024-10-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-18 | 2024-10-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-18 | 2024-10-18 | 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 | 2024-09-12 | 2024-10-18 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-09-12 | 2024-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-12 | 2024-10-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-12 | 2024-10-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-12 | 2024-10-18 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-01 | 2024-03-22 | 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 | 2023-05-26 | 2023-06-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-26 | 2023-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-26 | 2023-06-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-26 | 2023-06-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-26 | 2023-06-30 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-26 | 2023-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-26 | 2023-06-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-26 | 2023-06-30 | 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 | 2023-05-26 | 2023-06-30 | 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 | 2023-05-26 | 2023-06-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-26 | 2023-06-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-26 | 2023-06-30 | 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 | 2023-05-26 | 2023-06-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-26 | 2023-06-30 | 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 | 2023-05-26 | 2023-06-30 | 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 | 2023-05-26 | 2023-06-30 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-26 | 2023-06-30 | 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 | 2023-05-26 | 2023-06-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-26 | 2023-06-30 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-05-26 | 2023-06-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-26 | 2023-06-30 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-05-26 | 2023-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-26 | 2023-06-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-26 | 2023-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-26 | 2023-06-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-26 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-16 | 2023-06-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-23 | 2023-04-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-04-28 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-03-23 | 2023-04-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-23 | 2023-04-28 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-12-07 | 2023-01-18 | 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 | 2022-12-07 | 2023-01-18 | Y |
| Post nurse staffing information every day. | Health | 2022-12-07 | 2023-01-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-11 | 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 | 2022-07-13 | 2022-08-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-13 | 2022-08-08 | 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 | 2022-06-13 | 2022-08-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-13 | 2022-08-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-08-04 | Y |
| Provide appropriate foot care. | Health | 2022-07-13 | 2022-08-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-13 | 2022-08-04 | 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 | 2022-06-13 | 2022-08-04 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-06-13 | 2022-08-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-13 | 2022-08-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-13 | 2022-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-08-04 | Y |
| 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 | 2022-06-13 | 2022-08-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-13 | 2022-08-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-06-13 | 2022-08-04 | Y |
| 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 | 2022-06-13 | 2022-08-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-13 | 2022-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-13 | 2022-08-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-18 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-18 | 2022-04-29 | Y |
| 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 | 2022-03-18 | 2022-04-29 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-03-18 | 2022-04-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-16 | 2022-02-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-16 | 2022-02-04 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-12-16 | 2022-02-04 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-05-04 | 2021-05-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-04 | 2021-05-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-04 | 2021-05-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-04 | 2021-05-28 | 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 | 2021-05-04 | 2021-05-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-04 | 2021-05-28 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-04 | 2021-05-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-04 | 2021-05-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
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