A list of the most recent deficiencies for The Ambassador Sidney Inc. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-24 | 2023-04-04 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-02-24 | 2023-04-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-24 | 2023-04-04 | 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 | 2023-02-24 | 2023-04-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-02-24 | 2023-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-24 | 2023-04-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-24 | 2023-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-24 | 2023-03-07 | N |
| Have an externally vented heating system. | Fire Safety | 2023-02-24 | 2023-02-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-24 | 2023-02-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-24 | 2023-02-24 | 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 | 2021-12-06 | 2022-01-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-06 | 2022-01-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-02 | 2021-12-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-02 | 2021-12-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-02 | 2021-12-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-12-06 | 2021-12-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-06 | 2021-12-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-06 | 2021-12-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-06 | 2021-12-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-06 | 2021-12-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-06 | 2021-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-06 | 2021-12-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-06 | 2021-12-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-08 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-08 | 2021-10-29 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-14 | 2019-09-14 | 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 | 2019-08-08 | 2019-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-09-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-14 | 2019-09-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-14 | 2019-08-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-14 | 2019-08-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-08-14 | 2019-08-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-14 | 2019-08-19 | 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 | 2019-08-14 | 2019-08-15 | 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 | 2019-08-14 | 2019-08-14 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-08-14 | 2019-08-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-07 | Not Fixed | Y |
