Deficiency Records for South Dennis Healthcare
Updated as of October 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? |
---|---|---|---|---|
Implement emergency and standby power systems. | Fire Safety | 2023-07-10 | 2023-08-21 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-10 | 2023-08-21 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-10 | 2023-08-21 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-16 | 2023-07-21 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-16 | 2023-07-21 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-07-21 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-16 | 2023-07-21 | N |
Provide activities to meet all resident's needs. | Health | 2023-06-16 | 2023-07-21 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-16 | 2023-07-21 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-16 | 2023-07-21 | 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 | 2023-06-16 | 2023-07-21 | N |
Provide and implement an infection prevention and control program. | Health | 2023-06-16 | 2023-07-21 | N |
Implement a program that monitors antibiotic use. | Health | 2023-06-16 | 2023-07-21 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-16 | 2023-07-21 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-07-10 | 2023-07-13 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Create arrangements with other facilities to receive patients. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
List the names and contact information of those in the facility. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Implement emergency and standby power systems. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-01-12 | 2023-02-25 | N |
Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-01-11 | 2023-02-08 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-01-11 | 2023-02-08 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-11 | 2023-02-08 | 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 | 2023-01-11 | 2023-02-08 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-01-11 | 2023-02-08 | 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 | 2023-01-11 | 2023-02-08 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-11 | 2023-02-08 | N |
Provide activities to meet all resident's needs. | Health | 2023-01-11 | 2023-02-08 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-02-08 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-11 | 2023-02-08 | N |
Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-11 | 2023-02-08 | N |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-11 | 2023-02-08 | N |
Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-08 | N |
Implement a program that monitors antibiotic use. | Health | 2023-01-11 | 2023-02-08 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-11 | 2023-02-08 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-18 | 2023-01-21 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-18 | 2023-01-21 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-01-21 | Y |
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 |
Provide and implement an infection prevention and control program. | Health | 2023-09-15 | Not Fixed | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-15 | Not Fixed | N |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-09-15 | Not Fixed | N |