A list of the most recent deficiencies for Waterfall Health of Algoma. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-07 | 2024-01-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-08 | 2023-12-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-08 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-12-22 | 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 | 2023-11-08 | 2023-12-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-08 | 2023-12-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-08 | 2023-12-22 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2023-11-08 | 2023-12-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-11-07 | 2023-12-22 | 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 | 2023-11-07 | 2023-12-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-07 | 2023-12-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-10-13 | 2023-11-13 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2023-10-13 | 2023-11-13 | Y |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-10-13 | 2023-11-13 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-12 | 2022-11-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-10-12 | 2022-11-14 | 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 | 2022-10-12 | 2022-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-12 | 2022-11-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-12 | 2022-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-12 | 2022-10-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-10-12 | 2022-10-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-24 | 2021-09-17 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2021-08-24 | 2021-09-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-24 | 2021-09-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-08-24 | 2021-09-16 | 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 | 2021-08-24 | 2021-09-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-24 | 2021-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-24 | 2021-09-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-08-24 | 2021-09-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-25 | 2021-09-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-08-25 | 2021-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-25 | 2021-08-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-25 | 2021-08-25 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2023-11-07 | Not Fixed | 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 | 2023-11-07 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-07 | Not Fixed | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-07 | Not Fixed | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-07 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-07 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | Not Fixed | N |
