A list of the most recent deficiencies for Medina Bsd Opco LLC. 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? |
|---|---|---|---|---|
| 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 | 2022-06-23 | 2022-07-20 | 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 | 2022-06-23 | 2022-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-23 | 2022-07-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-23 | 2022-07-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-23 | 2022-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-23 | 2022-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-23 | 2022-07-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-23 | 2022-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-04 | 2022-04-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-04 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-04 | 2022-04-28 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-04 | 2022-04-28 | Y |
| 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 | 2022-04-04 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-27 | 2022-01-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-12 | 2019-08-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-12 | 2019-08-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-06-07 | 2018-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-07 | 2018-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-07 | 2018-07-06 | 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 | 2018-06-07 | 2018-07-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-07 | 2018-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-07 | 2018-07-06 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-06-07 | 2018-07-06 | N |
| Use approved construction type or materials. | Fire Safety | 2018-06-08 | 2018-07-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-08 | 2018-07-06 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-06-08 | 2018-07-06 | N |
