A list of the most recent deficiencies for Graham Hospital. 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 a two-hour-resistant firewall separation. | Fire Safety | 2023-12-06 | 2023-12-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-12-06 | 2023-12-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2023-11-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-02 | 2023-03-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-02 | 2023-03-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-02 | 2023-03-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-02 | 2023-02-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-02 | 2023-02-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-02-23 | 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 | 2023-02-02 | 2023-02-23 | 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 | 2023-02-02 | 2023-02-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Develop a communication plan. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish methods for sharing information. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-19 | 2021-05-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-17 | 2021-05-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-17 | 2021-05-01 | N |
