Deficiency Records for Catherine Kasper Home
Updated as of October 01, 2021
This is not the most recent data for Catherine Kasper Home. For the most recent information, click here.
A list of the most recent deficiencies for Catherine Kasper Home. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-12-28 | 2021-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-08 | 2021-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-26 | 2020-11-25 | N |
| Perform COVID19 testing on residents and staff. | Health | 2020-10-26 | 2020-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-07-21 | 2020-08-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-06-19 | 2020-07-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-06-19 | 2020-07-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-08 | 2019-09-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-08 | 2019-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-08 | 2019-09-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-08 | 2019-09-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-08 | 2019-09-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-08 | 2019-09-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-03 | 2019-07-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-06 | 2019-06-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-06 | 2019-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-06 | 2019-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-06 | 2019-06-03 | 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 | 2019-05-06 | 2019-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-06 | 2019-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-06 | 2019-06-03 | 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 | 2019-05-06 | 2019-06-03 | 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 | 2019-05-06 | 2019-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-06 | 2019-06-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-06 | 2019-06-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-06 | 2019-06-03 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-06-06 | 2018-07-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-06-06 | 2018-07-01 | 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 | 2018-06-06 | 2018-07-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-06 | 2018-07-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-18 | 2018-06-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-05-18 | 2018-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-18 | 2018-06-17 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-05-18 | 2018-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-18 | 2018-06-17 | 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 | 2018-05-18 | 2018-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-18 | 2018-06-17 | N |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2017-08-14 | 2017-09-13 | 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 | 2017-08-14 | 2017-09-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2017-08-14 | 2017-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-07-17 | 2017-08-16 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-07-17 | 2017-08-16 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-17 | 2017-08-16 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-07-17 | 2017-08-16 | N |
| Assess in a timely manner the resident when the resident enters the nursing home. | Health | 2017-07-17 | 2017-08-16 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-07-17 | 2017-08-16 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-17 | 2017-08-16 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-07-17 | 2017-08-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-07-17 | 2017-08-16 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-07-17 | 2017-08-16 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-17 | 2017-08-16 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-17 | 2017-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-17 | 2017-08-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-17 | 2017-08-16 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-07-17 | 2017-08-16 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-17 | 2017-08-16 | N |
