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Deficiency Records for Pope Nursing Home
View the most recent health deficiencies and inspection results for Pope Nursing Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Pope Nursing Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-04-22 | 2025-06-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-04-22 | 2025-06-06 | N |
| Dispose of garbage and refuse properly. | Health | 2025-04-22 | 2025-06-06 | 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 | 2025-04-22 | 2025-06-05 | 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 | 2025-04-22 | 2025-05-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2025-04-22 | 2025-05-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-04-22 | 2025-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-04-22 | 2025-05-25 | 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 | 2025-04-22 | 2025-05-25 | 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 (including nights and weekends) and emergencies. | Health | 2025-04-22 | 2025-05-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-04-22 | 2025-05-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-04-22 | 2025-05-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-04-22 | 2025-05-20 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-04-22 | 2025-05-20 | 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 | 2025-04-22 | 2025-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-04-22 | 2025-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-04-22 | 2025-05-16 | 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 | 2025-04-22 | 2025-05-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-04-22 | 2025-05-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2025-04-22 | 2025-05-05 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2025-04-22 | 2025-05-01 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2025-04-22 | 2025-05-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2025-04-22 | 2025-05-01 | 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 | 2025-04-22 | 2025-05-01 | N |
| Use approved construction type or materials. | Fire Safety | 2025-04-22 | 2025-05-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2025-04-22 | 2025-05-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2025-04-22 | 2025-05-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-04-22 | 2025-04-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-04-02 | 2024-06-05 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2024-04-02 | 2024-06-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-04-02 | 2024-06-05 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-04-02 | 2024-06-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-04-02 | 2024-06-05 | N |
| Use approved construction type or materials. | Fire Safety | 2024-04-02 | 2024-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-02 | 2024-05-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-02 | 2024-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-02 | 2024-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-02 | 2024-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-02 | 2024-05-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-04-02 | 2024-05-02 | 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 | 2024-04-02 | 2024-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-02 | 2024-04-22 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| 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 |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-02 | 2022-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-02 | 2022-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-02 | 2022-12-31 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-12-02 | 2022-12-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-02 | 2022-12-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-02 | 2022-12-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-02 | 2022-12-20 | 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 |