A list of the most recent deficiencies for Peace Healthcare at Dennett Road. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-02 | 2024-02-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-02 | 2024-02-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-02 | 2024-02-27 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-02 | 2024-02-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-02 | 2024-02-27 | Y |
| 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 | 2019-07-16 | 2019-08-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-07-16 | 2019-08-31 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-07-16 | 2019-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-16 | 2019-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-16 | 2019-08-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-16 | 2019-08-31 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-07-16 | 2019-08-31 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-07-16 | 2019-08-31 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-07-16 | 2019-08-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-16 | 2019-08-31 | 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 | 2019-07-16 | 2019-08-31 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-07-16 | 2019-08-31 | 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 | 2019-07-16 | 2019-08-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-16 | 2019-08-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-16 | 2019-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-16 | 2019-08-31 | 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 | 2019-07-16 | 2019-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-16 | 2019-08-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-07-16 | 2019-08-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-07-16 | 2019-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-26 | 2018-07-26 | 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 | 2018-04-26 | 2018-07-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-26 | 2018-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-26 | 2018-07-26 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-04-26 | 2018-07-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-04-26 | 2018-07-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-26 | 2018-07-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-26 | 2018-07-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-04-26 | 2018-07-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-26 | 2018-07-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-26 | 2018-07-10 | N |
| Provide activities to meet all resident's needs. | Health | 2018-04-26 | 2018-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-26 | 2018-07-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-04-26 | 2018-07-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-04-26 | 2018-07-10 | 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 | 2018-04-26 | 2018-07-10 | 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 | 2018-04-26 | 2018-07-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-26 | 2018-07-10 | N |
| Keep all essential equipment working safely. | Health | 2018-04-26 | 2018-07-10 | 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 | 2018-04-30 | 2018-06-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-30 | 2018-06-02 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-02-23 | 2017-04-17 | N |
| Provide housekeeping and maintenance services. | Health | 2017-02-23 | 2017-04-17 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-02-23 | 2017-04-17 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-02-23 | 2017-04-17 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-02-23 | 2017-04-17 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-02-23 | 2017-04-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-23 | 2017-04-17 | N |
| Keep all essential equipment working safely. | Health | 2017-02-23 | 2017-04-17 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2017-02-23 | 2017-04-17 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2017-02-23 | 2017-04-17 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-02-23 | 2017-04-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-02-28 | 2017-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-02-28 | 2017-04-05 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-02-28 | 2017-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-02-28 | 2017-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-28 | 2017-04-05 | N |
