A list of the most recent deficiencies for Russell Regional Hospital 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-02-07 | 2024-03-07 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-23 | 2022-09-23 | 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 | 2022-08-23 | 2022-09-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-27 | 2022-08-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-27 | 2022-08-14 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-06-27 | 2022-08-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-27 | 2022-08-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-27 | 2022-08-14 | 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 | 2022-06-27 | 2022-08-14 | 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 | 2022-06-27 | 2022-08-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-27 | 2022-08-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-17 | 2021-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-17 | 2021-07-15 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-03-06 | 2020-04-17 | 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 | 2020-03-06 | 2020-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-06 | 2020-04-17 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-01-17 | Not Fixed | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-17 | Not Fixed | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-01-17 | Not Fixed | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-17 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | Not Fixed | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-17 | Not Fixed | 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 | 2024-01-17 | Not Fixed | 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 | 2024-01-17 | Not Fixed | 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 | 2024-01-17 | Not Fixed | 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 | 2024-01-17 | Not Fixed | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-01-17 | Not Fixed | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-17 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-17 | Not Fixed | N |
