Deficiency Records for The Suites at Someren Glen Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Suites at Someren Glen Care Center. 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? |
|---|---|---|---|---|
| Perform COVID19 testing on residents and staff. | Health | 2023-01-30 | 2023-01-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-01 | 2022-12-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-01 | 2022-12-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-31 | 2022-05-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-31 | 2022-05-06 | Y |
| 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 | 2022-03-31 | 2022-05-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-31 | 2022-04-30 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-31 | 2022-04-30 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-03-10 | 2020-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-10 | 2020-05-22 | 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 | 2020-02-12 | 2020-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-12 | 2020-03-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-12 | 2020-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-12 | 2020-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-12 | 2020-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-12 | 2020-03-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-12 | 2020-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-19 | 2019-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-19 | 2019-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-19 | 2019-03-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-19 | 2019-03-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-19 | 2019-03-31 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-02-19 | 2019-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-19 | 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 | 2019-02-07 | 2019-03-12 | 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 | 2017-08-02 | 2017-08-22 | 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 | 2017-08-02 | 2017-08-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-08-02 | 2017-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-02 | 2017-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-02 | 2017-08-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-02 | 2017-08-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-02 | 2017-08-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-08-02 | 2017-08-22 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-07-06 | 2017-08-02 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-06 | 2017-08-02 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-07-06 | 2017-08-02 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-07-06 | 2017-08-02 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-06 | 2017-08-02 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-06 | 2017-08-02 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-06 | 2017-08-02 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-07-06 | 2017-08-02 | N |
