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Deficiency Records for Atherton Baptist Home
A list of the most recent deficiencies for Atherton Baptist Home. 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 Atherton Baptist Home. 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 a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-17 | 2024-02-01 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-20 | 2023-05-11 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-11 | 2022-12-22 | 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 | 2022-11-11 | 2022-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-11 | 2022-12-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-13 | 2022-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-13 | 2022-12-15 | 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 | 2022-11-13 | 2022-12-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-13 | 2022-12-15 | 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 | 2022-11-13 | 2022-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-13 | 2022-12-15 | 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 | 2022-11-13 | 2022-12-15 | 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 | 2022-11-13 | 2022-12-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-13 | 2022-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-13 | 2022-12-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-11-13 | 2022-12-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-29 | 2022-10-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-13 | 2022-09-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-13 | 2022-09-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-10 | 2022-07-10 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-07 | 2019-05-28 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-04-26 | 2019-05-24 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-04-26 | 2019-05-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-26 | 2019-05-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-26 | 2019-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-26 | 2019-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-26 | 2019-05-24 | 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 | 2019-04-26 | 2019-05-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-26 | 2019-05-24 | 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 | 2019-04-26 | 2019-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-26 | 2019-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-26 | 2019-05-24 | N |
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