Deficiency Records for South Dennis Healthcare
Updated as of February 01, 2023
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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-27 | 2022-08-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-10 | 2022-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-10 | 2022-06-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-10 | 2022-05-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-10 | 2022-05-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-10 | 2022-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-10 | 2022-05-31 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-12-10 | 2022-05-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-10 | 2022-05-31 | 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 | 2021-12-10 | 2022-05-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-10 | 2022-05-31 | 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 | 2021-12-10 | 2022-05-31 | 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 | 2021-12-10 | 2022-05-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-10 | 2022-05-31 | 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 | 2021-12-10 | 2022-05-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-10 | 2022-04-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-10 | 2022-04-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-10 | 2022-04-28 | 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 | 2021-12-10 | 2022-04-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-10 | 2022-03-31 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-12-10 | 2022-03-31 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2021-12-10 | 2022-03-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-10 | 2022-03-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-10 | 2022-03-29 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-10 | 2022-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-10 | 2022-03-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-12-10 | 2022-03-29 | 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 | 2021-12-10 | 2022-03-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-12-10 | 2022-03-29 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-12-10 | 2022-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2022-03-29 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-12-10 | 2022-03-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-10 | 2022-02-17 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-12-10 | 2022-02-17 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-12-10 | 2022-02-17 | 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 | 2021-12-10 | 2022-02-17 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-10 | 2022-02-17 | 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 | 2021-12-10 | 2022-02-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-10 | 2022-02-17 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-12-10 | 2022-02-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-10 | 2022-02-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-10 | 2022-02-17 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-10 | 2022-02-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-14 | 2022-01-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-14 | 2022-01-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-14 | 2022-01-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-14 | 2022-01-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-12-14 | 2021-12-30 | 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 | 2021-12-14 | 2021-12-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-14 | 2021-12-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-14 | 2021-12-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-14 | 2021-12-22 | N |
| 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 |
