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Deficiency Records for Five Counties Nursing Home
A list of the most recent deficiencies for Five Counties Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Five Counties Nursing Home. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2025-03-12 | 2025-05-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-12 | 2025-05-27 | 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 | 2025-03-12 | 2025-05-08 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2025-03-12 | 2025-05-07 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2025-03-12 | 2025-05-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2025-03-12 | 2025-04-26 | N |
| 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 | 2025-03-12 | 2025-04-26 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2025-03-12 | 2025-04-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-03-12 | 2025-04-26 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2025-03-12 | 2025-04-26 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2025-03-12 | 2025-04-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-03-12 | 2025-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-12 | 2025-04-26 | N |
| Post nurse staffing information every day. | Health | 2025-03-12 | 2025-04-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-03-12 | 2025-04-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2025-03-12 | 2025-04-26 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-03-12 | 2025-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-03-12 | 2025-04-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-03-12 | 2025-04-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2025-03-12 | 2025-04-26 | 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 | 2025-03-12 | 2025-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-22 | 2025-02-07 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-06 | 2024-01-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-06 | 2024-01-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-06 | 2024-01-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-06 | 2024-01-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-06 | 2024-01-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-06 | 2024-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-05 | 2024-01-04 | 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 | 2022-11-03 | 2022-12-23 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-02 | 2022-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-02 | 2022-12-01 | 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 | 2022-11-02 | 2022-12-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-02 | 2022-12-01 | N |
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