A list of the most recent deficiencies for Community Hospital Onaga Ltcu. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-07-12 | 2023-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-12 | 2023-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-12 | 2023-08-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-12 | 2023-08-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-12 | 2023-08-12 | 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 | 2023-06-19 | 2023-07-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-19 | 2023-07-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-19 | 2023-07-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-19 | 2023-07-05 | 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 | 2023-06-19 | 2023-07-05 | 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 | 2022-01-20 | 2022-02-28 | 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 | 2022-01-20 | 2022-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-20 | 2022-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-09 | 2020-02-11 | N |
