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Deficiency Records for Our Lady of Peace Inc
A list of the most recent deficiencies for Our Lady of Peace Inc. 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 Peace Inc. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-03-07 | 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 | 2023-01-12 | 2023-03-07 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-12 | 2023-03-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-12 | 2023-03-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-12 | 2023-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-23 | 2022-10-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-25 | 2021-04-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-25 | 2021-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-25 | 2021-04-30 | 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 | 2021-03-25 | 2021-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-04-30 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-24 | 2019-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-24 | 2019-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-24 | 2019-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-24 | 2019-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-08-15 | 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 | 2019-07-11 | 2019-08-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-11 | 2019-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-11 | 2019-08-15 | 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 | 2019-07-11 | 2019-08-15 | 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 | 2019-07-11 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-11 | 2019-08-15 | N |
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