Deficiency Records for Memorial Hospital Ltcu (village Manor)
Updated as of March 01, 2024
A list of the most recent deficiencies for Memorial Hospital Ltcu (village 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-06-29 | 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 | 2023-03-15 | 2023-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-04-15 | N |
| Meet other general requirements. | Fire Safety | 2023-03-15 | 2023-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-15 | 2023-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-20 | 2023-03-08 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-08 | 2023-03-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-08 | Y |
| 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 | 2023-02-08 | 2023-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-25 | 2022-08-05 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-09 | 2021-10-13 | 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 | 2021-09-09 | 2021-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-09 | 2021-10-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-09 | 2021-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-09 | 2021-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-09 | 2021-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-08-16 | 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 | 2019-06-24 | 2019-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-24 | 2019-07-22 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-06-04 | 2019-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-04 | 2019-06-20 | N |
