Deficiency Records for South Dennis Healthcare
Updated as of April 01, 2021
This is not the most recent data for South Dennis Healthcare. For the most recent information, click here.
A list of the most recent deficiencies for South Dennis 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? |
---|---|---|---|---|
Perform COVID19 testing on residents and staff. | Health | 2021-01-27 | 2021-02-23 | 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 | 2020-10-27 | 2020-12-16 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-27 | 2020-12-16 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-27 | 2020-12-16 | 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 | 2020-10-27 | 2020-12-16 | 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 | 2020-10-27 | 2020-12-16 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-10-27 | 2020-12-16 | N |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-10-27 | 2020-12-16 | N |
Provide and implement an infection prevention and control program. | Health | 2020-10-27 | 2020-12-16 | N |
Perform COVID19 testing on residents and staff. | Health | 2020-10-27 | 2020-12-16 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-27 | 2020-11-09 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-27 | 2020-11-09 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-22 | 2020-03-13 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Establish policies and procedures including evacuation. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Conduct testing and exercise requirements. | Fire Safety | 2020-01-22 | 2020-02-19 | 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 | 2020-01-22 | 2020-02-19 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-01-22 | 2020-02-19 | 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 | 2020-01-22 | 2020-02-19 | N |
Provide properly protected cooking facilities. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-22 | 2020-02-19 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2020-02-13 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-07 | 2020-02-13 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-07 | 2020-02-13 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-11-07 | 2020-02-13 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-07 | 2020-02-13 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-07 | 2020-02-13 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-11-07 | 2020-02-13 | 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 | 2019-11-07 | 2020-02-13 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-11-07 | 2020-01-13 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-07 | 2020-01-13 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-07 | 2020-01-13 | 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 | 2019-11-07 | 2020-01-13 | 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 | 2019-11-07 | 2020-01-13 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-11-07 | 2020-01-13 | N |
Provide activities to meet all resident's needs. | Health | 2019-11-07 | 2020-01-13 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-07 | 2020-01-13 | 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 | 2019-11-07 | 2020-01-13 | 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 | 2019-11-07 | 2020-01-13 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-11-07 | 2020-01-13 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-07 | 2020-01-13 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-07 | 2020-01-13 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-07 | 2020-01-13 | N |
Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2020-01-13 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-07 | 2020-01-13 | N |
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-11-07 | 2020-01-13 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-11-07 | 2020-01-13 | N |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-11-07 | 2020-01-13 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-22 | 2019-12-06 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-07 | 2019-05-02 | N |
Establish staff and initial training requirements. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
Meet other general requirements. | Fire Safety | 2019-02-07 | 2019-03-22 | 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 | 2019-02-07 | 2019-03-22 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-07 | 2019-03-22 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-11 | 2019-03-08 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-11 | 2019-02-21 | N |
Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-01-11 | 2019-02-21 | N |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-01-11 | 2019-02-21 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-11 | 2019-02-21 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-01-11 | 2019-02-21 | N |
Ensure each resident receives an accurate assessment. | Health | 2019-01-11 | 2019-02-21 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-11 | 2019-02-21 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-01-11 | 2019-02-21 | N |
Provide activities to meet all resident's needs. | Health | 2019-01-11 | 2019-02-21 | N |
Ensure the activities program is directed by a qualified professional. | Health | 2019-01-11 | 2019-02-21 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-11 | 2019-02-21 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | N |
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | N |
Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-11 | 2019-02-21 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-11 | 2019-02-21 | N |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-01-11 | 2019-02-21 | N |
Provide and implement an infection prevention and control program. | Health | 2019-01-11 | 2019-02-21 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-01-11 | 2019-02-21 | N |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-01-11 | 2019-02-21 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-01-11 | 2019-02-21 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-11 | 2019-02-21 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-12-17 | 2019-01-31 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-17 | 2019-01-31 | Y |
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-12-17 | 2019-01-31 | Y |