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 |