Deficiency Records for Nancy Hart Operation LLC
Updated as of May 01, 2024
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Deficiency Records for Nancy Hart Operation LLC
A list of the most recent deficiencies for Nancy Hart Operation LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Nancy Hart Operation LLC. 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? |
|---|---|---|---|---|
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-29 | 2024-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-21 | 2023-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-07-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-21 | 2023-07-12 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-01-06 | 2023-02-20 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-01-06 | 2023-02-20 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-01-06 | 2023-02-20 | Y |
| 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 | 2023-01-06 | 2023-02-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-01-06 | 2023-02-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-06 | 2023-02-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-06 | 2023-02-20 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-01-05 | 2023-02-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-16 | 2020-03-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-01-16 | 2020-03-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-16 | 2020-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-16 | 2020-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-16 | 2020-03-01 | 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 | 2020-01-16 | 2020-03-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-16 | 2020-03-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-16 | 2020-03-01 | 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 | 2020-01-16 | 2020-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-16 | 2020-03-01 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-01-16 | 2020-03-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-16 | 2020-03-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-01-16 | 2020-03-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-01-16 | 2020-03-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-01-14 | 2020-03-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-14 | 2020-03-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-14 | 2020-03-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-29 | Not Fixed | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-29 | Not Fixed | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-29 | Not Fixed | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-29 | Not Fixed | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-29 | Not Fixed | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-29 | Not Fixed | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-29 | Not Fixed | 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 | 2024-02-29 | Not Fixed | 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 | 2024-02-29 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-29 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-29 | Not Fixed | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-29 | Not Fixed | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-29 | Not Fixed | N |
| Meet other general requirements. | Fire Safety | 2024-02-29 | Not Fixed | N |
| Meet other general requirements. | Fire Safety | 2024-02-29 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-29 | Not Fixed | N |
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