A list of the most recent deficiencies for Dawson Place. 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 emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-01 | 2022-12-08 | 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 | 2022-11-01 | 2022-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-01 | 2022-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-01 | 2022-12-08 | 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 | 2022-10-13 | 2022-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-13 | 2022-11-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-11-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-13 | 2022-11-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-13 | 2022-11-23 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-10-13 | 2022-11-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-13 | 2022-11-23 | Y |
| Post nurse staffing information every day. | Health | 2022-10-13 | 2022-11-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-13 | 2022-11-23 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-10-13 | 2022-11-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-13 | 2022-11-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-13 | 2022-11-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-07 | 2022-02-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Develop a communication plan. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-22 | 2021-10-21 | 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 | 2021-09-22 | 2021-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-22 | 2021-09-22 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-08-16 | 2021-09-17 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-08-16 | 2021-09-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-16 | 2021-09-17 | 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 | 2021-08-16 | 2021-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-16 | 2021-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-16 | 2021-09-17 | 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 | 2021-08-16 | 2021-09-17 | 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 | 2021-08-16 | 2021-09-17 | N |
| 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 | 2021-08-16 | 2021-09-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-16 | 2021-09-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-16 | 2021-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-16 | 2021-09-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-30 | 2019-08-28 | 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 | 2019-07-30 | 2019-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-07-30 | 2019-08-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-07-09 | 2019-08-08 | 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 | 2019-07-09 | 2019-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-09 | 2019-07-31 | N |
