A list of the most recent deficiencies for Douglas Care Center LLC. 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-30 | 2023-10-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-30 | 2023-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-30 | 2023-10-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-30 | 2023-10-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-30 | 2023-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-30 | 2023-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-30 | 2023-10-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-30 | 2023-10-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-29 | 2023-10-16 | 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 | 2023-08-29 | 2023-10-16 | 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 | 2023-08-29 | 2023-10-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-29 | 2023-10-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-17 | 2023-01-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-11-17 | 2023-01-01 | Y |
| 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 | 2022-11-17 | 2023-01-01 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-12 | 2022-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-12 | 2022-10-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-10 | 2022-09-15 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-08-10 | 2022-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-10 | 2022-09-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-10 | 2022-09-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-10 | 2022-09-15 | 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 | 2022-08-12 | 2022-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-12 | 2022-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-12 | 2022-09-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-29 | 2021-08-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-29 | 2021-08-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-29 | 2021-08-18 | 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 | 2021-06-29 | 2021-08-18 | 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 | 2021-06-29 | 2021-08-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-06-29 | 2021-08-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-29 | 2021-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-29 | 2021-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-30 | 2021-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-05-27 | Y |
