Deficiency Records for East Ohio Regional Hospital Long Term Care
Updated as of April 01, 2024
A list of the most recent deficiencies for East Ohio Regional Hospital Long Term Care. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-20 | 2024-01-12 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-20 | 2024-01-12 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-29 | 2024-01-12 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2023-11-29 | 2024-01-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-29 | 2024-01-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-29 | 2024-01-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-11-29 | 2024-01-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-29 | 2024-01-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-29 | 2024-01-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-29 | 2024-01-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-29 | 2024-01-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-29 | 2024-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-29 | 2024-01-12 | 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 | 2023-11-29 | 2024-01-12 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-11-29 | 2024-01-12 | N |
| Post nurse staffing information every day. | Health | 2023-11-29 | 2024-01-12 | 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 | 2023-11-29 | 2024-01-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-29 | 2024-01-12 | 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 | 2023-11-29 | 2024-01-12 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-29 | 2024-01-12 | 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 | 2023-11-29 | 2024-01-12 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-11-29 | 2024-01-12 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-11-29 | 2024-01-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-29 | 2024-01-12 | 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 | 2023-11-29 | 2024-01-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-29 | 2024-01-12 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-29 | 2024-01-12 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-11-29 | 2024-01-12 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-11-29 | 2024-01-12 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-11-29 | 2024-01-12 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-29 | 2024-01-12 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-29 | 2024-01-12 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-11-29 | 2024-01-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-29 | 2024-01-12 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-29 | 2024-01-12 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-11-29 | 2024-01-12 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-29 | 2024-01-12 | Y |
| 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 | 2023-11-29 | 2024-01-12 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-29 | 2024-01-12 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-29 | 2024-01-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-29 | 2024-01-12 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-11-29 | 2024-01-12 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-29 | 2024-01-12 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-29 | 2024-01-12 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-29 | 2024-01-12 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-11-29 | 2024-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-29 | 2024-01-12 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-11-29 | 2024-01-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-29 | 2024-01-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-07 | 2024-01-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-04 | 2023-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-04 | 2023-05-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-04 | 2023-05-24 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-04-04 | 2023-05-24 | Y |
| 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 | 2023-04-04 | 2023-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-28 | 2023-01-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-28 | 2023-01-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-28 | 2023-01-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-28 | 2023-01-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-13 | 2022-07-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-06-13 | 2022-07-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-13 | 2022-07-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-13 | 2022-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-07-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-13 | 2022-07-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-13 | 2022-07-26 | 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 | 2022-06-13 | 2022-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-13 | 2022-07-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-13 | 2022-07-26 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-13 | 2022-07-26 | 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 | 2022-05-31 | 2022-07-26 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-31 | 2022-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-31 | 2022-07-26 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-06-13 | 2022-07-09 | N |
| Post nurse staffing information every day. | Health | 2022-06-13 | 2022-07-09 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-07-03 | 2019-08-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-03 | 2019-08-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-03 | 2019-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-03 | 2019-08-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-03 | 2019-08-15 | 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 | 2019-07-03 | 2019-08-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-03 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-03 | 2019-08-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-03 | 2019-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-08 | 2019-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-08 | 2019-08-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-08 | 2019-08-15 | N |
