A list of the most recent deficiencies for Pope Nursing Home. 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? |
|---|---|---|---|---|
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-12-02 | 2023-01-05 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-02 | 2023-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-02 | 2022-12-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-12-02 | 2022-12-05 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-12-02 | 2022-12-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-02 | 2022-12-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-02 | 2022-12-05 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-23 | 2021-08-17 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-12-23 | 2021-08-17 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-12-23 | 2021-08-17 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2019-12-23 | 2021-08-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-23 | 2021-08-17 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-12-23 | 2021-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-23 | 2020-02-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-23 | 2019-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-23 | 2019-12-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-17 | 2019-12-25 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-10-17 | 2019-12-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-17 | 2019-12-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-17 | 2019-12-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-17 | 2019-12-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-17 | 2019-12-25 | 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 | 2019-10-17 | 2019-12-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-17 | 2019-12-25 | 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 | 2019-10-17 | 2019-12-25 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-17 | 2019-12-25 | 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 | 2019-10-17 | 2019-12-25 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-17 | 2019-12-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-17 | 2019-12-25 | 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 | 2019-10-17 | 2019-12-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-23 | 2019-12-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-04 | 2019-01-03 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-10-04 | 2018-10-30 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-10-04 | 2018-10-30 | 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 | 2018-10-04 | 2018-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-10-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Use approved construction type or materials. | Fire Safety | 2018-10-04 | 2018-10-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-10-04 | 2018-10-19 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-10-04 | 2018-10-19 | 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 | 2018-10-04 | 2018-10-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-04 | 2018-10-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-04 | 2018-10-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-04 | 2018-10-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-04 | 2018-10-19 | N |
