A list of the most recent deficiencies for Smiths Mill Health Campus. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-06 | 2023-08-04 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-06 | 2023-08-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-06 | 2023-08-04 | 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 | 2023-07-06 | 2023-08-04 | 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 | 2023-07-06 | 2023-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-06 | 2023-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-08-04 | 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 | 2023-07-06 | 2023-08-04 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-03 | 2023-08-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-03 | 2023-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-31 | 2023-04-19 | 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 | 2023-03-31 | 2023-04-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-17 | 2022-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2022-12-08 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-22 | 2022-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-09-13 | 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 | 2022-08-22 | 2022-09-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-14 | 2022-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-14 | 2022-03-29 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-17 | 2022-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-17 | 2022-03-29 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-17 | 2021-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-17 | 2021-12-10 | 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 | 2021-11-17 | 2021-12-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-02 | 2021-09-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-12 | 2021-07-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-12 | 2021-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-12 | 2021-07-30 | 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 | 2021-07-12 | 2021-07-30 | Y |
| 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 | 2021-07-12 | 2021-07-30 | Y |
| 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 | 2021-06-20 | 2021-07-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-20 | 2021-07-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-20 | 2021-07-30 | Y |
