A list of the most recent deficiencies for Abbey Senior Health. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-06-15 | 2023-12-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-06-09 | 2023-07-24 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-09 | 2023-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-09 | 2023-07-24 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-06-09 | 2023-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-07-24 | 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 | 2023-06-09 | 2023-07-24 | 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 | 2023-06-09 | 2023-07-24 | 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 | 2023-06-09 | 2023-07-24 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-09 | 2023-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-24 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-09 | 2023-07-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-07-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-09 | 2023-07-24 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-06-15 | 2023-07-24 | 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 | 2023-06-15 | 2023-07-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Meet other general requirements. | Fire Safety | 2023-06-15 | 2023-07-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-22 | 2021-05-12 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-11-07 | 2020-11-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-07 | 2019-12-20 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-11-07 | 2019-12-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-07 | 2019-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2019-12-20 | N |
| Use approved construction type or materials. | Fire Safety | 2018-12-20 | 2019-12-20 | 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 | 2019-11-07 | 2019-11-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-11-07 | 2019-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-07 | 2019-11-07 | 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 | 2018-12-20 | 2019-02-03 | 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 | 2018-12-20 | 2019-02-03 | 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 | 2018-12-20 | 2019-02-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-20 | 2019-02-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-12-20 | 2019-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-20 | 2019-02-03 | N |
