A list of the most recent deficiencies for Melrose 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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-26 | 2023-06-29 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-07 | 2023-03-31 | 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 | 2023-02-07 | 2023-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-07 | 2023-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-07 | 2023-03-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-07 | 2023-03-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-07 | 2023-03-10 | 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 | 2023-02-07 | 2023-03-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-07 | 2023-03-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-07 | 2023-03-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-07 | 2023-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-07 | 2023-03-10 | 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 | 2023-02-07 | 2023-03-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-07 | 2023-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-07 | 2023-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-07 | 2023-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-07 | 2023-03-10 | 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 | 2023-02-07 | 2023-03-10 | 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 | 2023-02-07 | 2023-03-10 | 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 | 2023-02-07 | 2023-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-07 | 2023-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-07 | 2023-03-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-07 | 2021-11-08 | 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 | 2021-10-07 | 2021-11-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-07 | 2021-11-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-07 | 2021-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-07 | 2021-11-08 | 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 | 2021-10-07 | 2021-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-07 | 2021-11-08 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-07 | 2021-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-07 | 2021-11-08 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-07 | 2021-11-08 | N |
| Provide appropriate foot care. | Health | 2021-10-07 | 2021-11-08 | 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 | 2021-10-07 | 2021-11-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-07 | 2021-11-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-07 | 2021-11-08 | 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 | 2021-10-07 | 2021-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-07 | 2021-11-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-07 | 2021-11-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-07 | 2021-11-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-07 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-08 | 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 | 2019-02-28 | 2019-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-28 | 2019-03-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-28 | 2019-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-28 | 2019-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-28 | 2019-03-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-28 | 2019-03-22 | N |
| Provide activities to meet all resident's needs. | Health | 2019-02-28 | 2019-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-28 | 2019-03-22 | 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 | 2019-02-28 | 2019-03-22 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-02-28 | 2019-03-22 | 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 | 2019-02-28 | 2019-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-28 | 2019-03-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-28 | 2019-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-28 | 2019-03-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-28 | 2019-03-22 | N |
