A list of the most recent deficiencies for Memorial Heights Nursing Center. 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? |
|---|---|---|---|---|
| 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 | 2024-02-01 | 2024-02-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-01 | 2024-02-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-01 | 2024-02-29 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-02-01 | 2024-02-29 | 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 | 2024-02-01 | 2024-02-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-02-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-01 | 2024-02-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-01 | 2024-02-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-01 | 2023-02-03 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-12-01 | 2023-02-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-12-01 | 2023-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-01 | 2023-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-01 | 2023-02-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-01 | 2023-02-03 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2022-12-01 | 2023-02-03 | 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 | 2022-12-01 | 2023-02-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-01 | 2023-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-18 | 2021-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-18 | 2021-09-20 | 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 | 2021-08-18 | 2021-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-09-20 | 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 | 2021-08-17 | 2021-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-17 | 2021-09-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-17 | 2021-09-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-17 | 2021-09-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-17 | 2021-09-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-17 | 2021-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-14 | 2019-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-14 | 2019-06-12 | N |
