Deficiency Records for Sligo Creek Healthcare
Updated as of February 01, 2021
This is not the most recent data for Sligo Creek Healthcare. For the most recent information, click here.
A list of the most recent deficiencies for Sligo Creek Healthcare. 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? |
|---|---|---|---|---|
| Report COVID19 data to residents and families. | Health | 2020-07-29 | 2020-08-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-05 | 2020-01-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-05 | 2020-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-01-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-05 | 2020-01-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-05 | 2020-01-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-21 | 2019-06-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-21 | 2019-06-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-21 | 2019-06-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-21 | 2019-06-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-05-21 | 2019-06-26 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-21 | 2019-06-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-10 | 2019-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-10 | 2019-06-14 | 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 | 2019-05-10 | 2019-06-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-10 | 2019-06-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-10 | 2019-06-14 | 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 | 2019-05-10 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-10 | 2019-06-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-05-10 | 2019-06-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-10 | 2019-06-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-10 | 2019-06-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-07 | 2019-04-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-18 | 2019-02-08 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2018-08-14 | 2018-09-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-14 | 2018-09-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-08-14 | 2018-09-14 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-05-15 | 2018-06-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-05-15 | 2018-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-15 | 2018-06-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-15 | 2018-06-22 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-05-15 | 2018-06-22 | 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 | 2018-05-15 | 2018-06-22 | 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 | 2018-05-15 | 2018-06-22 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-05-15 | 2018-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-15 | 2018-06-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-15 | 2018-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-15 | 2018-06-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-05-15 | 2018-06-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-05-15 | 2018-06-22 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-16 | 2018-06-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-16 | 2018-06-10 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-02-28 | 2018-03-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-28 | 2018-03-23 | Y |
| Meet other general requirements. | Fire Safety | 2017-06-15 | 2017-08-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-06-15 | 2017-08-04 | 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 | 2017-06-15 | 2017-08-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-06-15 | 2017-08-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-06-15 | 2017-08-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-15 | 2017-08-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-06-15 | 2017-08-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-15 | 2017-08-04 | N |
| Give notice to the resident before a room or roommate change. | Health | 2017-03-31 | 2017-05-19 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-03-31 | 2017-05-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-31 | 2017-05-19 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-31 | 2017-05-19 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2017-03-31 | 2017-05-19 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-03-31 | 2017-05-19 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-31 | 2017-05-19 | N |
| Dispose of garbage and refuse properly. | Health | 2017-03-31 | 2017-05-19 | N |
| Provide or obtain dental services for each resident. | Health | 2017-03-31 | 2017-05-19 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-31 | 2017-05-19 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-31 | 2017-05-19 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-03-31 | 2017-05-19 | N |
| Give or get x-rays and other tests in a timely manner to meet the needs of residents. | Health | 2017-03-31 | 2017-05-19 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-31 | 2017-05-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-03-31 | 2017-05-19 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-11-20 | Not Fixed | Y |
