A list of the most recent deficiencies for The Episcopal Church Home. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2023-03-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-14 | 2023-03-01 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-11-14 | 2023-01-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-14 | 2022-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-27 | 2022-12-01 | 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 | 2022-11-14 | 2022-11-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-13 | 2020-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-13 | 2020-01-29 | 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 | 2019-12-13 | 2020-01-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-13 | 2020-01-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-13 | 2020-01-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-11 | 2020-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-11 | 2019-12-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-12-11 | 2019-12-13 | 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 | 2018-10-05 | 2018-11-16 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-10-05 | 2018-11-16 | 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 | 2018-10-05 | 2018-11-16 | 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 | 2018-10-05 | 2018-11-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-05 | 2018-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-05 | 2018-11-16 | N |
| Keep all essential equipment working safely. | Health | 2018-10-05 | 2018-11-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-05 | 2018-11-16 | 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 | 2018-10-02 | 2018-11-16 | N |
