A list of the most recent deficiencies for Stephenson Nursing Center. 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-18 | 2024-02-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-18 | 2024-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-18 | 2024-02-10 | 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 | 2024-01-18 | 2024-02-10 | 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 | 2024-01-18 | 2024-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-18 | 2024-02-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-18 | 2024-02-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-09 | 2024-01-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-09 | 2024-01-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-09 | 2024-01-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-09 | 2024-01-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-12 | 2023-12-19 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-01-12 | 2023-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-12 | 2023-03-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-01-12 | 2023-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-23 | 2023-02-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-23 | 2023-02-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-02-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-12 | 2023-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-12 | 2023-02-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-12 | 2023-02-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-12 | 2023-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-12 | 2023-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-12 | 2023-01-19 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-01-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-12 | 2023-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-22 | 2023-01-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-22 | 2022-12-31 | Y |
| 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 | 2022-12-08 | 2022-12-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-08 | 2022-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-08 | 2022-12-31 | 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 | 2022-12-08 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-08 | 2022-04-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-08 | 2022-04-14 | 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 | 2022-04-07 | 2022-04-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Establish methods for sharing information. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-08 | 2022-04-07 | 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 | 2022-03-08 | 2022-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-08 | 2022-04-07 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-03 | 2022-04-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-03 | 2022-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-03 | 2022-03-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-03 | 2022-03-23 | 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 | 2022-03-03 | 2022-03-23 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-03 | 2022-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-31 | 2022-02-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-30 | 2021-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-30 | 2021-10-15 | Y |
