A list of the most recent deficiencies for Ingleside 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-01 | 2023-11-27 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-05-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-30 | 2023-05-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-30 | 2023-05-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-30 | 2023-05-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-30 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-05-05 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-03-30 | 2023-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-30 | 2023-05-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-30 | 2023-05-05 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-28 | 2023-05-05 | 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 | 2023-03-28 | 2023-05-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-28 | 2023-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-04-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-31 | 2022-11-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-31 | 2022-11-16 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-10-31 | 2022-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-01 | 2022-03-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-12 | 2022-02-07 | Y |
| 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 | 2021-12-01 | 2021-12-27 | 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 | 2021-12-01 | 2021-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-01 | 2021-12-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-29 | 2021-12-27 | 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 | 2021-11-29 | 2021-12-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-29 | 2021-12-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-22 | 2021-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-22 | 2021-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-15 | 2021-06-30 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-30 | 2019-11-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-30 | 2019-11-06 | 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 | 2019-10-01 | 2019-10-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-01 | 2019-10-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-01 | 2019-10-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-01 | 2019-10-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-30 | 2019-10-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-30 | 2019-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-30 | 2019-10-08 | N |
