A list of the most recent deficiencies for Tuff Memorial 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-12-11 | 2024-01-02 | 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 | 2023-09-27 | 2023-12-15 | 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 | 2023-09-27 | 2023-12-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-27 | 2023-12-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-27 | 2023-12-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-27 | 2023-12-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-27 | 2023-12-15 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-09-27 | 2023-12-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-27 | 2023-12-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-09-27 | 2023-12-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-27 | 2023-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-26 | 2023-10-20 | 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 | 2022-09-09 | 2022-11-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-09 | 2022-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-11-01 | N |
| Report COVID19 data to residents and families. | Health | 2022-09-09 | 2022-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-09 | 2022-11-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-09 | 2022-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-30 | 2021-11-28 | Y |
| 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 | 2021-05-26 | 2021-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-26 | 2021-06-15 | N |
