A list of the most recent deficiencies for Dutchtown Care Center. 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? |
|---|---|---|---|---|
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-01 | 2023-03-20 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-11-30 | 2023-01-31 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-08 | 2022-12-08 | 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 | 2021-12-08 | 2022-04-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-08 | 2022-04-30 | 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 | 2021-12-08 | 2022-04-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-08 | 2022-04-30 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2021-12-08 | 2022-04-30 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-08 | 2022-04-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-08 | 2022-04-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-08 | 2022-04-30 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-08 | 2022-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-16 | 2022-04-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-16 | 2022-04-30 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-16 | 2022-04-30 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-08 | 2022-03-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-08 | 2022-03-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-18 | 2022-03-04 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-01-18 | 2022-03-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-18 | 2022-03-04 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-12-08 | 2022-01-22 | 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 | 2021-12-08 | 2022-01-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-08 | 2022-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-08 | 2022-01-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-08 | 2022-01-22 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-12-08 | 2022-01-22 | N |
| Provide appropriate foot care. | Health | 2021-12-08 | 2022-01-22 | N |
| Post nurse staffing information every day. | Health | 2021-12-08 | 2022-01-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-12-08 | 2022-01-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-08 | 2022-01-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-08 | 2022-01-22 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-08 | 2022-01-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-08 | 2022-01-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-08 | 2022-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-08 | 2022-01-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-08 | 2022-01-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-08 | 2022-01-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-08 | 2022-01-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-08 | 2022-01-22 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-08 | 2022-01-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-12-08 | 2022-01-22 | 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 | 2021-12-08 | 2022-01-22 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-08 | 2022-01-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-06 | 2019-10-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-06 | 2019-10-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-09-06 | 2019-10-18 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-09-06 | 2019-10-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-06 | 2019-10-18 | 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 | 2019-09-06 | 2019-10-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-06 | 2019-10-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-06 | 2019-10-18 | 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 | 2019-09-06 | 2019-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-06 | 2019-10-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-06 | 2019-10-18 | 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 | 2019-09-06 | 2019-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-06 | 2019-10-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-06 | 2019-10-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-26 | 2018-12-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-10-26 | 2018-12-10 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-10-26 | 2018-12-10 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-10-26 | 2018-12-10 | N |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2018-10-26 | 2018-12-10 | 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 | 2018-10-26 | 2018-12-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-26 | 2018-12-10 | 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 | 2018-10-26 | 2018-12-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-26 | 2018-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-26 | 2018-12-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-26 | 2018-12-10 | 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 | 2018-10-26 | 2018-12-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-26 | 2018-12-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-26 | 2018-12-10 | 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 | 2018-10-26 | 2018-12-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-10-26 | 2018-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-26 | 2018-12-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-26 | 2018-12-10 | N |
| Use approved construction type or materials. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Have an externally vented heating system. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-26 | 2018-12-10 | N |
