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Deficiency Records for Jerold Phelps Comm Hosp Snf
A list of the most recent deficiencies for Jerold Phelps Comm Hosp Snf. 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 Jerold Phelps Comm Hosp Snf. 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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-05 | 2024-04-20 | 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 | 2024-03-05 | 2024-04-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-03-05 | 2024-04-20 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-01 | 2024-04-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-01 | 2024-04-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-01 | 2024-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-01 | 2024-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-01 | 2024-04-09 | 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 | 2024-03-01 | 2024-04-09 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-03-01 | 2024-04-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-02-01 | 2023-03-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-10-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-10-04 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-20 | 2021-07-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-05-20 | 2021-07-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-20 | 2021-07-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-20 | 2021-07-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-20 | 2021-07-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-20 | 2021-07-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-20 | 2021-07-22 | 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 | 2021-05-20 | 2021-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-20 | 2021-07-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-20 | 2021-07-22 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-20 | 2021-07-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-22 | 2019-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-22 | 2019-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-22 | 2019-10-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-17 | 2019-10-16 | N |
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