Deficiency Records for Dundee Manor, LLC
Updated as of July 01, 2023
This is not the most recent data for Dundee Manor, LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-07-10 | 2018-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-13 | 2018-08-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-07-13 | 2018-08-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-13 | 2018-08-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-13 | 2018-08-27 | 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 | 2018-07-13 | 2018-08-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-13 | 2018-08-27 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-13 | 2018-08-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-13 | 2018-08-27 | 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 | 2018-07-13 | 2018-08-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-13 | 2018-08-27 | N |
