A list of the most recent deficiencies for Pittsfield Manor. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-02 | 2024-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-02 | 2024-01-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-02 | 2024-01-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-01-02 | 2024-01-18 | 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 | 2024-01-02 | 2024-01-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-02 | 2024-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-19 | 2024-01-16 | N |
| 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 | 2024-01-02 | 2024-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-02 | 2024-01-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-19 | 2024-01-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-02 | 2024-01-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-12-19 | 2024-01-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-19 | 2024-01-07 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-01-02 | 2024-01-05 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-02 | 2024-01-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-19 | 2024-01-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-20 | 2023-07-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-20 | 2023-07-07 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-11-17 | 2022-12-31 | 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 | 2022-11-17 | 2022-12-31 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-17 | 2022-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-17 | 2022-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-17 | 2022-12-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-22 | 2022-12-27 | 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 | 2022-11-22 | 2022-12-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-22 | 2022-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-22 | 2022-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-22 | 2022-12-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-22 | 2022-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-22 | 2022-12-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-17 | 2022-12-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-17 | 2022-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2022-12-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-11-17 | 2022-12-06 | N |
| Develop a communication plan. | Fire Safety | 2022-11-17 | 2022-12-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-11-17 | 2022-12-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-17 | 2022-12-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-26 | 2022-11-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-26 | 2022-11-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-31 | 2022-09-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-31 | 2022-09-16 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-07 | 2022-02-01 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-01-06 | 2022-01-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-06 | 2022-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-01-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-01-06 | 2022-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-06 | 2022-01-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-06 | 2022-01-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Develop a communication plan. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-07 | 2022-01-10 | N |
