A list of the most recent deficiencies for Hoeger House. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-31 | 2023-10-01 | Y |
| 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 | 2023-08-31 | 2023-10-01 | 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 | 2023-08-31 | 2023-10-01 | Y |
| 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 | 2023-08-31 | 2023-10-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-10-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-05-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-08 | 2022-04-20 | 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 | 2022-03-08 | 2022-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-08 | 2022-04-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-27 | 2022-03-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-27 | 2022-03-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-27 | 2022-03-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-27 | 2022-03-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-27 | 2022-03-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-27 | 2022-03-10 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-01-27 | 2022-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-13 | 2020-02-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-13 | 2020-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-13 | 2020-02-14 | 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 | 2020-01-13 | 2020-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-13 | 2020-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-13 | 2020-02-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-13 | 2020-02-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-13 | 2020-02-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-13 | 2020-02-14 | 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 | 2020-01-13 | 2020-02-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-28 | 2019-11-08 | N |
