A list of the most recent deficiencies for Dr Guy Gorman Sr Care 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? |
|---|---|---|---|---|
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-15 | 2024-01-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-13 | 2023-11-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-15 | 2023-11-17 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-15 | 2023-11-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-15 | 2023-11-17 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-15 | 2023-11-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-15 | 2023-11-17 | 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 | 2023-09-15 | 2023-11-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-09-15 | 2023-11-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-09-15 | 2023-11-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-15 | 2023-11-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-15 | 2023-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-15 | 2023-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-15 | 2023-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-15 | 2023-11-17 | 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 | 2023-09-15 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-15 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-15 | 2023-11-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-15 | 2023-11-17 | N |
| Have a Compliance and Ethics Program. | Health | 2023-09-15 | 2023-11-17 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-09-15 | 2023-11-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-14 | 2023-06-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-14 | 2023-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-14 | 2023-06-16 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-04-14 | 2023-06-16 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-30 | 2022-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-30 | 2022-12-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-18 | 2022-11-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-30 | 2022-11-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-30 | 2022-11-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-30 | 2022-11-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-30 | 2022-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-30 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-30 | 2022-11-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-30 | 2022-11-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-30 | 2022-11-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-30 | 2022-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-30 | 2022-11-18 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-30 | 2022-11-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-30 | 2022-10-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-30 | 2022-10-28 | 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 | 2022-08-30 | 2022-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-10-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-30 | 2022-10-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-30 | 2022-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-30 | 2022-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-27 | 2022-02-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-27 | 2022-01-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-27 | 2022-01-27 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-09-27 | 2022-01-27 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-09-27 | 2022-01-27 | 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 | 2021-09-27 | 2022-01-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-09-27 | 2022-01-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-09-27 | 2022-01-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-27 | 2022-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-27 | 2022-01-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-09-27 | 2022-01-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-27 | 2022-01-27 | 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 | 2021-09-27 | 2022-01-27 | 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 | 2021-09-27 | 2022-01-27 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-27 | 2022-01-27 | 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 | 2021-09-27 | 2022-01-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-09-27 | 2022-01-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-09-27 | 2022-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-27 | 2022-01-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-09-27 | 2022-01-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-27 | 2022-01-27 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-09-27 | 2022-01-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-27 | 2022-01-27 | Y |
| 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 | 2021-09-27 | 2022-01-27 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-09-27 | 2022-01-27 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-09-24 | 2021-11-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-24 | 2021-11-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-24 | 2021-11-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-09-24 | 2021-11-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-09-24 | 2021-11-15 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-09-24 | 2021-11-15 | N |
| Establish methods for sharing information. | Fire Safety | 2021-09-24 | 2021-11-15 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-09-24 | 2021-10-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-24 | 2021-10-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-24 | 2021-10-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-24 | 2021-10-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-24 | 2021-10-19 | N |
