A list of the most recent deficiencies for Hannah Duston Healthcare Center. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-22 | 2023-12-31 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-25 | 2023-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-13 | 2023-05-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-13 | 2023-05-26 | N |
| 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 | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-13 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-05-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-05-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-06 | 2023-05-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-06 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-06 | 2023-05-12 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-01 | 2022-05-16 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-04-01 | 2022-05-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-03-14 | 2022-04-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-14 | 2022-04-20 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-14 | 2022-04-20 | 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 | 2022-03-14 | 2022-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide appropriate foot care. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-14 | 2022-04-20 | 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 | 2022-03-14 | 2022-04-20 | N |
| Provide or obtain dental services for each resident. | Health | 2022-03-14 | 2022-04-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-14 | 2022-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-14 | 2022-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-14 | 2022-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-14 | 2022-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-14 | 2022-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-06-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-06-13 | Y |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-09-23 | 2019-11-04 | 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 | 2019-09-23 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-23 | 2019-10-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-19 | 2019-08-28 | 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 | 2019-07-19 | 2019-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-19 | 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 | 2019-07-19 | 2019-08-28 | N |
