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Deficiency Records for Sulphur Springs Health and Rehabilitation
A list of the most recent deficiencies for Sulphur Springs Health and Rehabilitation. 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 Sulphur Springs Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-12 | 2024-09-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-12 | 2024-01-19 | 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 | 2023-12-12 | 2024-01-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-12 | 2024-01-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-15 | 2023-12-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-15 | 2023-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-15 | 2023-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-15 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-15 | 2023-12-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-15 | 2023-12-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | 2023-12-20 | 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 | 2023-11-15 | 2023-12-20 | 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 | 2023-11-15 | 2023-12-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-11-15 | 2023-12-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-15 | 2023-12-20 | 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 | 2023-11-15 | 2023-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-15 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-15 | 2023-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-15 | 2023-12-20 | N |
| Have policies on smoking. | Health | 2023-11-15 | 2023-12-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-20 | 2023-07-31 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-18 | 2022-11-17 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-05 | 2022-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-05 | 2022-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-05 | 2022-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-11-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-05 | 2022-11-04 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-05 | 2022-11-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-05 | 2022-11-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-05 | 2022-11-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-05 | 2022-11-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-05 | 2022-11-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-10-05 | 2022-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-05 | 2022-11-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-05 | 2022-11-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-05 | 2022-11-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-13 | 2022-09-12 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-13 | 2021-10-13 | 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 | 2021-09-13 | 2021-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-13 | 2021-10-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-01 | 2021-10-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-01 | 2021-10-02 | 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 | 2021-09-01 | 2021-10-02 | 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 | 2021-09-01 | 2021-10-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-09-01 | 2021-10-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-01 | 2021-10-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-01 | 2021-10-02 | N |
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