A list of the most recent deficiencies for Lewis County Nursing Home District. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-17 | 2024-01-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-11-17 | 2024-01-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-17 | 2024-01-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-17 | 2024-01-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-17 | 2024-01-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-17 | 2024-01-01 | 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 | 2023-11-17 | 2024-01-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-17 | 2024-01-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2024-01-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-17 | 2024-01-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-17 | 2024-01-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-29 | 2024-01-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-29 | 2024-01-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-11-29 | 2024-01-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-17 | 2023-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-13 | 2023-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-21 | 2021-06-23 | 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 | 2021-05-21 | 2021-06-23 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-21 | 2021-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-21 | 2021-06-23 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-05-21 | 2021-06-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-05-21 | 2021-06-23 | 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 | 2021-05-21 | 2021-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-21 | 2021-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-11 | 2019-05-25 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-11 | 2019-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-11 | 2019-05-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-11 | 2019-05-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-11 | 2019-05-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-17 | Not Fixed | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-17 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-17 | Not Fixed | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-11-17 | Not Fixed | N |
