Deficiency Records for Archie Hendricks Senior Skilled Nursing Facility
Updated as of March 01, 2024
A list of the most recent deficiencies for Archie Hendricks Senior Skilled Nursing Facility. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-14 | 2023-10-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-14 | 2023-10-16 | 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 | 2023-09-14 | 2023-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-14 | 2023-10-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-14 | 2023-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-14 | 2023-10-16 | 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 | 2023-09-14 | 2023-10-10 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-14 | 2023-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-10 | 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 | 2023-09-14 | 2023-10-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-14 | 2023-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-14 | 2023-10-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-14 | 2023-10-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-14 | 2023-10-10 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-14 | 2023-10-10 | 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 | 2023-09-14 | 2023-10-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-14 | 2023-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-14 | 2023-10-10 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-14 | 2023-10-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-25 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-09 | 2022-10-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-08-09 | 2022-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-09 | 2022-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-11 | 2022-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-11 | 2022-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-11 | 2022-09-30 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-08-11 | 2022-09-30 | 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 | 2022-08-11 | 2022-09-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-11 | 2022-09-30 | 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 | 2022-08-09 | 2022-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-09 | 2022-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-09 | 2022-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-09 | 2022-09-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-09 | 2022-09-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-27 | 2021-10-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-27 | 2021-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-27 | 2021-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-10-13 | Y |
