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? |
|---|---|---|---|---|
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-27 | 2021-05-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-27 | 2021-05-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-27 | 2021-05-21 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-04-27 | 2021-05-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-27 | 2021-05-21 | Y |
| 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 |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-12 | 2018-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-12 | 2018-09-19 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-08-15 | 2018-09-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-08-15 | 2018-09-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-15 | 2018-09-19 | N |
