A list of the most recent deficiencies for The Village of East Harbor. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-10-12 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-30 | 2023-05-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-30 | 2023-05-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-30 | 2023-05-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-29 | 2023-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-29 | 2023-05-01 | 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 | 2023-03-29 | 2023-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-05-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-29 | 2023-05-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-30 | 2023-04-30 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-03-30 | 2023-04-30 | N |
| Develop a communication plan. | Fire Safety | 2023-03-30 | 2023-04-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-30 | 2023-04-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-03-30 | 2023-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-30 | 2023-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-30 | 2023-03-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-14 | 2023-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-14 | 2023-03-10 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-08 | 2022-06-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-08 | 2022-05-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-08 | 2022-05-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-08 | 2022-05-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-08 | 2022-05-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-10 | 2022-04-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-04-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-10 | 2022-04-22 | 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 | 2022-02-10 | 2022-04-22 | 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 | 2022-02-10 | 2022-04-22 | 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 | 2022-02-10 | 2022-04-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-10 | 2022-04-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-10 | 2022-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-04-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-08 | 2022-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-04-08 | N |
| Post nurse staffing information every day. | Health | 2019-10-23 | 2019-11-30 | 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 | 2019-10-23 | 2019-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-23 | 2019-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-23 | 2019-11-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-23 | 2019-11-30 | 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 | 2019-10-21 | 2019-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2019-11-30 | N |
