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Deficiency Records for Smiths Mill Health Campus
A list of the most recent deficiencies for Smiths Mill Health Campus. 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 Smiths Mill Health Campus. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-01-17 | 2025-02-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-17 | 2025-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-17 | 2025-02-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-09 | 2024-11-05 | 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 | 2024-10-09 | 2024-11-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-09 | 2024-11-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-10-09 | 2024-11-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-09 | 2024-11-05 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-10-09 | 2024-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-10-09 | 2024-11-05 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-10-09 | 2024-11-05 | 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 | 2024-10-09 | 2024-11-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-09 | 2024-11-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-09 | 2024-11-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-10-09 | 2024-11-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-01 | 2024-11-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-01 | 2024-11-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-07 | 2024-08-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-08-07 | 2024-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-03 | 2024-08-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-03 | 2024-08-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-03 | 2024-08-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-06 | 2023-08-04 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-06 | 2023-08-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-06 | 2023-08-04 | 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 | 2023-07-06 | 2023-08-04 | 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 | 2023-07-06 | 2023-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-06 | 2023-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-08-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-06 | 2023-08-04 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-03 | 2023-08-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-03 | 2023-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-31 | 2023-04-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-31 | 2023-04-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-17 | 2022-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2022-12-08 | Y |
| 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 | 2022-08-22 | 2022-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-09-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-22 | 2022-09-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-14 | 2022-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-14 | 2022-03-29 | Y |
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