Deficiency Records for Our Lady of Peace Nursing Care Residence
Updated as of April 01, 2024
A list of the most recent deficiencies for Our Lady of Peace Nursing Care Residence. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-07-25 | 2023-09-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-25 | 2023-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2023-01-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-23 | 2023-01-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-23 | 2023-01-20 | Y |
| Develop a communication plan. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2022-11-23 | 2023-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-10 | 2020-02-25 | 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 | 2020-01-10 | 2020-02-25 | 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 | 2020-01-10 | 2020-02-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-10 | 2020-02-25 | 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 | 2020-01-10 | 2020-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-10 | 2020-02-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-12 | 2019-02-08 | 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 | 2018-12-12 | 2019-02-08 | 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 | 2018-12-12 | 2019-02-08 | N |
