A list of the most recent deficiencies for The Bishop Spencer Place, Inc. 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? |
|---|---|---|---|---|
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-02-06 | 2024-03-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-06 | 2024-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-06 | 2024-03-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-06 | 2024-03-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-06 | 2024-03-22 | 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 | 2024-02-06 | 2024-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-06 | 2024-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-06 | 2024-03-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-06 | 2024-03-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-06 | 2024-03-22 | 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 | 2024-02-06 | 2024-03-22 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2024-02-06 | 2024-03-22 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-08-29 | 2023-09-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-06 | 2023-07-03 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-06 | 2023-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-21 | 2023-01-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-19 | 2022-09-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-19 | 2022-09-02 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-07-19 | 2022-09-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-19 | 2022-09-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-04 | 2021-06-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-19 | 2019-11-02 | 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 | 2019-09-19 | 2019-11-02 | 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 | 2019-09-19 | 2019-11-02 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-09-19 | 2019-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-19 | 2019-11-02 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-09-19 | 2019-11-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-19 | 2019-11-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-19 | 2019-11-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-19 | 2019-11-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-19 | 2019-11-02 | N |
