A list of the most recent deficiencies for Foss Home and Village. 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? |
|---|---|---|---|---|
| Keep all essential equipment working safely. | Health | 2023-10-27 | 2023-12-04 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-10 | 2023-03-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-10 | 2023-03-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-10 | 2023-03-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-10 | 2023-03-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-10 | 2023-03-09 | 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 | 2023-02-10 | 2023-03-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-10 | 2023-03-09 | 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 | 2023-02-10 | 2023-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-10 | 2023-03-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Establish methods for sharing information. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-17 | 2023-03-09 | 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 | 2023-02-17 | 2023-03-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-02-17 | 2023-03-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-17 | 2023-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-24 | 2023-02-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-24 | 2023-02-07 | Y |
| Report COVID19 data to residents and families. | Health | 2023-01-24 | 2023-02-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-08 | 2022-09-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-03 | 2021-12-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-12-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-03 | 2021-12-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-03 | 2021-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-11-03 | 2021-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-03 | 2021-12-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-03 | 2021-12-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-10 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-10-21 | 2021-11-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-18 | 2019-01-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-12-18 | 2019-01-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-12-18 | 2019-01-29 | N |
| 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 | 2018-12-18 | 2019-01-29 | 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 | 2018-12-18 | 2019-01-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-12-18 | 2019-01-29 | N |
| Respond appropriately to all alleged violations. | Health | 2018-12-18 | 2019-01-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-12-18 | 2019-01-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-12-18 | 2019-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-18 | 2019-01-29 | 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 | 2018-12-18 | 2019-01-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-18 | 2019-01-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-18 | 2019-01-29 | 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 | 2018-12-18 | 2019-01-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-12-18 | 2019-01-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-18 | 2019-01-29 | 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 | 2018-12-18 | 2019-01-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-18 | 2019-01-29 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-12-18 | 2019-01-29 | 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 | 2018-12-18 | 2019-01-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-12-18 | 2019-01-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-06 | 2019-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-06 | 2019-01-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-06 | 2019-01-04 | N |
