A list of the most recent deficiencies for Midtown Manor. 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 and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-30 | 2023-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-30 | 2023-10-25 | 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 | 2023-08-30 | 2023-10-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-30 | 2023-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-30 | 2023-10-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-30 | 2023-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-30 | 2023-10-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-28 | 2023-10-15 | 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 | 2023-08-28 | 2023-10-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-28 | 2023-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-28 | 2023-10-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-28 | 2022-01-15 | 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 | 2021-10-28 | 2022-01-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-28 | 2022-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-28 | 2022-01-15 | 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 | 2021-10-28 | 2022-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2022-01-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-28 | 2022-01-15 | N |
| Post nurse staffing information every day. | Health | 2021-10-28 | 2022-01-15 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-28 | 2022-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-28 | 2022-01-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-28 | 2022-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2022-01-15 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-10-28 | 2022-01-15 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-01 | 2021-12-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-01 | 2021-12-30 | 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 | 2021-11-01 | 2021-12-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-01 | 2021-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-29 | 2019-10-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-08-29 | 2019-10-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-29 | 2019-10-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-29 | 2019-10-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-08-29 | 2019-10-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-29 | 2019-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-29 | 2019-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-29 | 2019-10-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-29 | 2019-10-28 | 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 | 2019-08-29 | 2019-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-29 | 2019-10-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-08-29 | 2019-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-29 | 2019-10-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-26 | 2019-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-26 | 2019-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-26 | 2019-10-20 | N |
