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Deficiency Records for White Sulphur Springs Center
A list of the most recent deficiencies for White Sulphur Springs 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 White Sulphur Springs 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-09 | 2024-08-19 | 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 | 2024-07-09 | 2024-08-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-09 | 2024-08-19 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-07-11 | 2024-08-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-07-11 | 2024-08-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-11 | 2024-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-11 | 2024-08-13 | 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 | 2024-07-11 | 2024-08-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-11 | 2024-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-11 | 2024-08-13 | 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 | 2024-07-11 | 2024-08-13 | N |
| Post nurse staffing information every day. | Health | 2024-07-11 | 2024-08-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-07-11 | 2024-08-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-07-11 | 2024-08-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-11 | 2024-08-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-11 | 2024-08-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-07-11 | 2024-08-13 | 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 | 2024-07-11 | 2024-08-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-07-11 | 2024-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-11 | 2024-08-13 | N |
| Dispose of garbage and refuse properly. | Health | 2024-07-11 | 2024-08-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-11 | 2024-08-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-07-11 | 2024-08-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-07-11 | 2024-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-11 | 2024-08-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-11 | 2024-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-11 | 2024-08-13 | Y |
| 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 | 2023-03-07 | 2023-04-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-07 | 2023-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-07 | 2023-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-07 | 2023-04-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-08 | 2023-03-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-08 | 2023-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-08 | 2023-03-27 | 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 | 2023-03-08 | 2023-03-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-08 | 2023-03-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-08 | 2023-03-27 | 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 | 2023-03-08 | 2023-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-08 | 2023-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-08 | 2023-03-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-08 | 2023-03-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-08 | 2023-03-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-01 | 2021-12-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-01 | 2021-12-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-01 | 2021-12-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-12-01 | 2021-12-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-01 | 2021-12-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-01 | 2021-12-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-01 | 2021-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-01 | 2021-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-01 | 2021-12-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-12-01 | 2021-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-01 | 2021-12-10 | N |
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