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Deficiency Records for Foss Home and Village
A list of the most recent deficiencies for Foss Home and Village. 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 Foss Home and Village. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-07-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-23 | 2024-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-23 | 2024-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-30 | 2024-06-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-30 | 2024-06-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-30 | 2024-06-14 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2024-04-30 | 2024-06-14 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-04-30 | 2024-06-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-04-30 | 2024-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-30 | 2024-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-30 | 2024-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-04-30 | 2024-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-30 | 2024-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-30 | 2024-06-14 | 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 | 2024-04-30 | 2024-06-14 | N |
| Post nurse staffing information every day. | Health | 2024-04-30 | 2024-06-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-04-23 | 2024-06-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-16 | 2024-05-31 | Y |
| Keep all essential equipment working safely. | Health | 2023-10-27 | 2023-12-04 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-10 | 2023-03-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-10 | 2023-03-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-10 | 2023-03-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-10 | 2023-03-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-10 | 2023-03-09 | 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 | 2023-02-10 | 2023-03-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-10 | 2023-03-09 | 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 | 2023-02-10 | 2023-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-10 | 2023-03-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish methods for sharing information. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-17 | 2023-03-09 | 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 | 2023-02-17 | 2023-03-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-17 | 2023-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-24 | 2023-02-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-24 | 2023-02-07 | Y |
| Report COVID19 data to residents and families. | Health | 2023-01-24 | 2023-02-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-08 | 2022-09-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-03 | 2021-12-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-12-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-03 | 2021-12-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-03 | 2021-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-11-03 | 2021-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-03 | 2021-12-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-03 | 2021-12-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-10 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
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