A list of the most recent deficiencies for The H and J Vonderlieth Lvg Ctr. 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? |
|---|---|---|---|---|
| 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 | 2023-08-03 | 2023-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-02 | 2023-08-16 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-08-02 | 2023-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-08-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-08-09 | 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 | 2023-08-02 | 2023-08-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-02 | 2023-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-07-18 | 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 | 2022-06-30 | 2022-07-18 | 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 | 2022-07-13 | 2022-07-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-13 | 2022-07-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-04-30 | 2021-05-19 | 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 | 2021-04-30 | 2021-05-19 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-04-30 | 2021-05-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-30 | 2021-05-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-30 | 2021-05-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-04-30 | 2021-05-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-30 | 2021-05-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-30 | 2021-05-13 | N |
| Provide two separate exits in rooms of more than 1000 square feet. | Fire Safety | 2021-04-30 | 2021-05-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-30 | 2021-05-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-30 | 2021-05-03 | N |
| 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 | 2021-04-02 | 2021-04-23 | 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 | 2021-04-02 | 2021-04-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-02 | 2021-04-23 | N |
