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Deficiency Records for Embassy of Hillsdale Park
A list of the most recent deficiencies for Embassy of Hillsdale Park. 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 Embassy of Hillsdale Park. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-18 | 2024-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-18 | 2024-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-18 | 2024-06-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-11 | 2024-05-15 | 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 | 2024-04-11 | 2024-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-11 | 2024-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-11 | 2024-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-11 | 2024-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-11 | 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 | 2024-04-11 | 2024-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-11 | 2024-05-15 | 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 | 2024-04-11 | 2024-05-15 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-04-11 | 2024-05-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-11 | 2024-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-20 | 2024-04-12 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-11 | 2023-07-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-05-11 | 2023-07-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-11 | 2023-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-07-01 | 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 | 2023-05-11 | 2023-07-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-11 | 2023-07-01 | 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 | 2023-05-11 | 2023-07-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-11 | 2023-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-07-01 | 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 | 2023-05-18 | 2023-06-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-05-18 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-18 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-18 | 2023-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-18 | 2023-06-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-18 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-18 | 2023-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-23 | 2023-04-30 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-30 | 2022-08-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-30 | 2022-08-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-30 | 2022-08-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-30 | 2022-08-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-30 | 2022-08-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-30 | 2022-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-30 | 2022-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-30 | 2022-08-10 | 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 | 2022-06-30 | 2022-08-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-30 | 2022-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-08-10 | 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 | 2022-06-30 | 2022-08-10 | 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 | 2022-06-30 | 2022-08-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-30 | 2022-08-10 | 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 | 2022-06-30 | 2022-08-10 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-30 | 2022-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-08-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-16 | 2022-01-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-08 | 2022-01-05 | Y |
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