A list of the most recent deficiencies for Holladay Park Plaza. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-13 | 2023-04-26 | N |
| 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 | 2023-03-13 | 2023-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-13 | 2023-04-26 | 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 | 2023-03-13 | 2023-04-26 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-13 | 2023-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-13 | 2023-04-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-13 | 2023-04-26 | N |
| 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 | 2023-03-13 | 2023-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-04-26 | 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 | 2023-03-13 | 2023-04-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-03-13 | 2023-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-04-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-13 | 2023-04-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-13 | 2023-04-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-13 | 2023-04-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-13 | 2023-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-13 | 2023-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-13 | 2023-04-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-28 | 2022-06-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-29 | 2022-06-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-29 | 2022-06-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-23 | 2021-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-05-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-22 | 2021-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-22 | 2021-05-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-22 | 2021-05-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-22 | 2021-05-26 | N |
