A list of the most recent deficiencies for Darcy Hall of Life Care. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-08 | 2023-12-08 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-05 | 2023-10-30 | 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 | 2023-10-05 | 2023-10-30 | 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 | 2023-10-05 | 2023-10-30 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-05 | 2023-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-10-30 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2023-10-05 | 2023-10-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-20 | 2023-10-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-27 | 2022-07-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-09 | 2022-07-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-09 | 2022-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-09 | 2022-07-09 | 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 | 2022-06-09 | 2022-07-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-09 | 2022-07-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-09 | 2022-07-09 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-11 | 2022-05-14 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-02-08 | 2022-03-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-05 | 2022-02-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-05 | 2022-02-05 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-09 | 2022-01-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-09 | 2022-01-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-08 | 2021-11-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-08 | 2021-11-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-22 | 2021-07-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-22 | 2021-07-12 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-22 | 2021-07-12 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-22 | 2021-07-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-22 | 2021-07-12 | 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 | 2021-05-22 | 2021-07-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-22 | 2021-07-12 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-22 | 2021-07-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-22 | 2021-07-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-22 | 2021-07-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-22 | 2021-07-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-22 | 2021-07-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-22 | 2021-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-22 | 2021-07-12 | 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 | 2021-05-22 | 2021-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-22 | 2021-07-12 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-22 | 2021-07-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-05-22 | 2021-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-22 | 2021-07-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-22 | 2021-07-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-22 | 2021-07-12 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-22 | 2021-07-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-22 | 2021-07-12 | 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 | 2021-05-22 | 2021-07-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-05-22 | 2021-07-12 | 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 | 2021-05-22 | 2021-07-12 | 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 | 2021-05-22 | 2021-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-22 | 2021-07-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-05-22 | 2021-07-12 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2021-05-22 | 2021-07-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-22 | 2021-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-22 | 2021-07-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-06-04 | 2021-07-04 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-06-04 | 2021-07-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-04 | 2021-07-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-04 | 2021-07-04 | N |
