A list of the most recent deficiencies for Touchmark On South Hill Nursing. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-31 | 2023-10-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-31 | 2023-10-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-31 | 2023-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-31 | 2023-10-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-31 | 2023-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-10-11 | 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 | 2023-08-31 | 2023-10-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-31 | 2023-10-11 | 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 | 2023-08-31 | 2023-10-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-31 | 2023-10-11 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-31 | 2023-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-31 | 2023-10-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-01 | 2023-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-22 | 2023-01-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2023-01-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2023-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2023-01-10 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-29 | 2022-05-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-03-31 | 2022-05-06 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-03-31 | 2022-05-06 | 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 | 2022-03-31 | 2022-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-31 | 2022-05-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-31 | 2022-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-29 | 2022-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-29 | 2022-04-15 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-05-19 | 2021-07-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-19 | 2021-07-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-31 | 2021-07-02 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-12 | 2020-01-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-12 | 2020-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-12 | 2020-01-24 | 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 | 2019-12-12 | 2020-01-24 | 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 | 2019-12-12 | 2020-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-11 | 2020-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-11 | 2020-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-11 | 2020-01-10 | N |
| Have a properly installed medical gas master alarm panel. | Fire Safety | 2019-12-11 | 2020-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-11 | 2020-01-10 | N |
