A list of the most recent deficiencies for Thornton Terrace Health Campus. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-01-31 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-01-11 | 2024-01-31 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-07-17 | 2023-08-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-17 | 2023-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-17 | 2023-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-17 | 2023-08-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-17 | 2023-08-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-03 | 2023-07-21 | 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 | 2023-07-03 | 2023-07-21 | 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 | 2023-07-03 | 2023-07-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-15 | 2023-05-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-11 | 2022-07-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-21 | 2022-07-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-21 | 2022-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-21 | 2022-07-03 | 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 | 2022-06-21 | 2022-07-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-08 | 2021-06-23 | Y |
| 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 | 2020-01-06 | 2020-01-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-06 | 2020-01-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-06 | 2020-01-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-06 | 2020-01-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-06 | 2020-01-27 | 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 | 2019-10-24 | 2019-10-31 | N |
