Deficiency Records for A Holly Patterson Extended Care Facility
Updated as of March 01, 2024
A list of the most recent deficiencies for A Holly Patterson Extended Care Facility. 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? |
|---|---|---|---|---|
| Have proper power supply for life support equipment. | Fire Safety | 2022-03-09 | 2022-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-09 | 2022-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-09 | 2022-04-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-03-09 | 2022-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-09 | 2022-04-29 | 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 | 2022-03-09 | 2022-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-09 | 2022-04-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-09 | 2022-04-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-03-09 | 2022-04-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-09 | 2022-04-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-09 | 2022-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-24 | 2022-02-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-10-17 | 2019-12-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-17 | 2019-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-17 | 2019-12-13 | 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 | 2019-10-17 | 2019-12-10 | N |
| Develop a communication plan. | Fire Safety | 2018-06-08 | 2018-08-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-08 | 2018-08-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-06-08 | 2018-08-06 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2018-06-08 | 2018-08-06 | 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 | 2018-06-06 | 2018-08-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-06 | 2018-08-05 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-10-17 | Not Fixed | N |
