A list of the most recent deficiencies for Dundee Manor, 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-25 | 2024-02-09 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-29 | 2023-09-08 | Y |
| 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 | 2023-05-11 | 2023-06-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-11 | 2023-06-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-05-11 | 2023-06-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-11 | 2023-06-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-11 | 2023-06-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-11 | 2023-06-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-11 | 2023-06-08 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-04-27 | 2022-04-30 | 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 | 2021-08-12 | 2021-09-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-12 | 2021-09-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-12 | 2021-09-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-12 | 2021-09-17 | 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 | 2021-08-12 | 2021-09-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-12 | 2021-09-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-12 | 2021-09-17 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-08-12 | 2021-09-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-12 | 2021-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-12 | 2021-09-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-12 | 2021-09-17 | 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 | 2021-08-12 | 2021-09-17 | N |
| Keep all essential equipment working safely. | Health | 2021-08-12 | 2021-09-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-12 | 2021-09-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-12 | 2021-09-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-10 | 2021-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-19 | 2019-12-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-19 | 2019-10-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-19 | 2019-10-21 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-09-19 | 2019-10-21 | N |
| Keep all essential equipment working safely. | Health | 2019-09-19 | 2019-10-21 | N |
