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Deficiency Records for Our Lady of Hope Health Center
A list of the most recent deficiencies for Our Lady of Hope Health Center. 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 Our Lady of Hope Health Center. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-27 | 2023-10-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-27 | 2023-10-17 | 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 | 2023-09-27 | 2023-10-17 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-09-27 | 2023-10-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-03 | 2023-05-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-03 | 2023-05-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-03 | 2023-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-03 | 2023-05-17 | 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 | 2023-05-03 | 2023-05-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-14 | 2022-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-14 | 2022-02-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-14 | 2022-02-18 | 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 | 2021-12-09 | 2021-12-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-09 | 2021-12-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-12-09 | 2021-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2021-12-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-03 | 2021-01-20 | 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 | 2020-03-03 | 2021-01-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-03 | 2021-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-03 | 2021-01-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-03 | 2021-01-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-03-03 | 2021-01-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-03 | 2021-01-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-03 | 2021-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-03 | 2021-01-20 | 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 | 2020-02-27 | 2020-04-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-27 | 2020-04-03 | 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 | 2020-02-27 | 2020-04-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-27 | 2020-04-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-02-27 | 2020-04-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-27 | 2020-04-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-04-03 | 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 | 2020-02-27 | 2020-04-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-27 | 2020-04-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-27 | 2020-04-03 | 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 | 2020-02-27 | 2020-04-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-27 | 2020-04-03 | N |
| Dispose of garbage and refuse properly. | Health | 2020-02-27 | 2020-04-03 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2020-02-27 | 2020-04-03 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-02-27 | 2020-04-03 | N |
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