A list of the most recent deficiencies for Spurgeon Manor. 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? |
|---|---|---|---|---|
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-10-12 | 2023-10-27 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-12 | 2023-10-27 | 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 | 2023-10-12 | 2023-10-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-12 | 2023-10-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-12 | 2023-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-12 | 2023-10-27 | 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 | 2023-10-12 | 2023-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-10-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-12 | 2023-10-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-16 | 2023-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-02-28 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-07-14 | 2022-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-14 | 2022-07-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-14 | 2022-07-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-03-25 | 2021-04-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-25 | 2021-04-19 | 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 | 2021-03-25 | 2021-04-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-25 | 2021-04-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-25 | 2021-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-25 | 2021-03-26 | 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 | 2021-03-17 | 2021-03-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-03-17 | 2021-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-17 | 2021-03-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-03-17 | 2021-03-19 | N |
