A list of the most recent deficiencies for Providence Place at Glencroft. 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? |
|---|---|---|---|---|
| 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 | 2023-05-12 | 2023-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-12 | 2023-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-12 | 2023-08-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-12 | 2023-07-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-12 | 2023-07-28 | N |
| Post nurse staffing information every day. | Health | 2023-05-12 | 2023-07-28 | 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 | 2023-05-12 | 2023-07-28 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-05-12 | 2023-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-07-28 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-05-12 | 2023-07-28 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-05-12 | 2023-07-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-14 | 2023-07-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-19 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-19 | 2023-06-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-19 | 2023-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-08 | 2023-01-19 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-04-08 | 2022-05-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-08 | 2022-05-06 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-04-08 | 2022-05-05 | 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 | 2022-04-08 | 2022-05-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-13 | 2020-08-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-13 | 2020-08-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-13 | 2020-08-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-13 | 2020-08-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-13 | 2020-02-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-13 | 2020-02-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-13 | 2020-02-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-13 | 2020-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-13 | 2020-02-15 | 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 | 2019-12-13 | 2020-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-13 | 2020-02-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-13 | 2020-02-15 | 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 | 2019-12-13 | 2020-02-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-12-13 | 2020-02-15 | 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 | 2019-12-13 | 2020-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-12 | 2020-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-12 | 2020-02-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-12 | 2020-02-10 | N |
