A list of the most recent deficiencies for Community Manor. 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-23 | 2023-03-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-23 | 2023-03-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-23 | 2023-03-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-03-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-23 | 2023-03-26 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-02-23 | 2023-03-26 | N |
| Dispose of garbage and refuse properly. | Health | 2023-02-23 | 2023-03-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-23 | 2023-03-26 | 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 | 2023-02-23 | 2023-03-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-23 | 2023-03-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-23 | 2023-03-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-26 | 2022-06-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-28 | 2020-04-06 | 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 | 2020-02-28 | 2020-04-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-28 | 2020-04-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-28 | 2020-04-06 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2020-02-28 | 2020-04-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-28 | 2020-04-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-28 | 2020-04-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-28 | 2020-04-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-28 | 2020-04-06 | N |
| 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 | 2020-02-28 | 2020-04-06 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-28 | 2020-04-06 | 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 | 2020-02-28 | 2020-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-28 | 2020-04-06 | 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 | 2020-02-28 | 2020-04-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-28 | 2020-04-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-28 | 2020-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-28 | 2020-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-28 | 2020-04-06 | 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 | 2020-02-28 | 2020-04-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-28 | 2020-04-06 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-01-30 | 2019-03-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-30 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-30 | 2019-03-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-30 | 2019-03-15 | N |
| Post nurse staffing information every day. | Health | 2019-01-30 | 2019-03-15 | 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 | 2019-01-30 | 2019-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-30 | 2019-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-30 | 2019-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-30 | 2019-03-15 | N |
