A list of the most recent deficiencies for Our Lady of Perpetual Help. 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? |
|---|---|---|---|---|
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-10-18 | 2021-12-03 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-14 | 2021-11-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-10-14 | 2021-11-28 | 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 | 2021-10-14 | 2021-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-14 | 2021-11-28 | N |
| Provide appropriate foot care. | Health | 2021-10-14 | 2021-11-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-14 | 2021-11-28 | 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 | 2021-10-14 | 2021-11-28 | 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 | 2021-10-14 | 2021-11-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-10-14 | 2021-11-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-14 | 2021-11-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-14 | 2021-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-09 | 2019-11-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-10-09 | 2019-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-02 | 2019-10-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-02 | 2019-10-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-02 | 2019-10-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-02 | 2019-10-16 | 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 | 2018-04-13 | 2018-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-13 | 2018-04-30 | N |
