A list of the most recent deficiencies for Episcopal Church Home of Minnesota. 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? |
---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-13 | 2023-08-31 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-25 | 2023-03-24 | Y |
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-25 | 2023-03-24 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-09 | 2023-01-13 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-20 | 2022-12-23 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-20 | 2022-12-23 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-20 | 2022-12-23 | 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 | 2022-10-20 | 2022-12-23 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-20 | 2022-12-23 | N |
Ensure that residents are free from significant medication errors. | Health | 2022-10-20 | 2022-12-23 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-12-23 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-21 | 2022-12-23 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-18 | 2022-12-23 | N |
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-10-18 | 2022-12-23 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-20 | 2022-05-28 | Y |
Ensure staff are vaccinated for COVID-19 | Health | 2022-03-17 | 2022-03-29 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-16 | 2021-11-18 | Y |
Provide properly protected cooking facilities. | Fire Safety | 2021-06-08 | 2021-08-31 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-08 | 2021-08-31 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-10 | 2021-07-29 | 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 | 2021-06-10 | 2021-07-29 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-07-29 | 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 | 2021-06-10 | 2021-07-29 | 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 | 2021-06-10 | 2021-07-29 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-07-29 | N |
Provide and implement an infection prevention and control program. | Health | 2021-06-10 | 2021-07-29 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-08 | 2021-07-28 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-08 | 2021-07-01 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-08 | 2021-07-01 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-01 | 2019-03-13 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-01 | 2019-03-13 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-01 | 2019-03-13 | N |
Ensure each resident receives an accurate assessment. | Health | 2019-02-01 | 2019-03-13 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-01 | 2019-03-13 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-01 | 2019-03-13 | N |
Provide activities to meet all resident's needs. | Health | 2019-02-01 | 2019-03-13 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-01 | 2019-03-13 | 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 | 2019-02-01 | 2019-03-13 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-01-30 | 2019-03-13 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-01-30 | 2019-03-13 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-30 | 2019-03-13 | N |