Deficiency Records for Atherton Baptist Home

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Updated as of April 01, 2024

A list of the most recent deficiencies for Atherton Baptist Home. 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?
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-17 2024-02-01 Y
Address subsistence needs for staff and patients. Fire Safety 2023-11-21 2023-12-15 N
Implement emergency and standby power systems. Fire Safety 2023-11-21 2023-12-15 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-11-21 2023-12-15 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 2023-11-21 2023-12-15 N
Provide properly protected cooking facilities. Fire Safety 2023-11-21 2023-12-15 N
Construct fire resistant interior walls. Fire Safety 2023-11-21 2023-12-15 N
Install an approved automatic sprinkler system. Fire Safety 2023-11-21 2023-12-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-21 2023-12-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-11-21 2023-12-15 N
Install properly constructed windows in hallway walls or doors. Fire Safety 2023-11-21 2023-12-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-11-21 2023-12-15 N
Have power receptacles that are properly grounded. Fire Safety 2023-11-21 2023-12-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-11-21 2023-12-15 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-11-21 2023-12-15 N
Have proper medical gas storage and administration areas. Fire Safety 2023-11-21 2023-12-15 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-11-16 2023-12-08 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 2023-11-16 2023-12-08 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-16 2023-12-08 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 2023-11-16 2023-12-08 N
Provide enough food/fluids to maintain a resident's health. Health 2023-11-16 2023-12-08 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2023-11-16 2023-12-08 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 2023-11-16 2023-12-08 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-16 2023-12-08 N
Provide and implement an infection prevention and control program. Health 2023-11-16 2023-12-08 N
Provide and implement an infection prevention and control program. Health 2023-04-20 2023-05-11 Y
Provide emergency officials' contact information. Fire Safety 2022-11-11 2022-12-22 N
Implement emergency and standby power systems. Fire Safety 2022-11-11 2022-12-22 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-11-11 2022-12-22 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 2022-11-11 2022-12-22 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-11-11 2022-12-22 N
Install an approved automatic sprinkler system. Fire Safety 2022-11-11 2022-12-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-11-11 2022-12-22 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-11-11 2022-12-22 N
Have proper medical gas storage and administration areas. Fire Safety 2022-11-11 2022-12-22 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-11-13 2022-12-15 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-11-13 2022-12-15 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 2022-11-13 2022-12-15 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-11-13 2022-12-15 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-11-13 2022-12-15 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-11-13 2022-12-15 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 2022-11-13 2022-12-15 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 2022-11-13 2022-12-15 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2022-11-13 2022-12-15 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-11-13 2022-12-15 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2022-11-13 2022-12-15 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2022-09-29 2022-10-21 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-09-13 2022-09-26 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-09-13 2022-09-26 Y
Provide and implement an infection prevention and control program. Health 2022-06-10 2022-07-10 Y
Establish roles under a Waiver declared by secretary. Fire Safety 2019-05-07 2019-05-28 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-05-07 2019-05-28 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 2019-05-07 2019-05-28 N
Have properly located and lighted "Exit" signs. Fire Safety 2019-05-07 2019-05-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-05-07 2019-05-28 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-05-07 2019-05-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-05-07 2019-05-28 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-05-07 2019-05-28 N
The resident has the right to receive notices in a format and a language he or she understands. Health 2019-04-26 2019-05-24 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2019-04-26 2019-05-24 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2019-04-26 2019-05-24 N
Keep residents' personal and medical records private and confidential. Health 2019-04-26 2019-05-24 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-04-26 2019-05-24 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-04-26 2019-05-24 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 2019-04-26 2019-05-24 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-04-26 2019-05-24 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 2019-04-26 2019-05-24 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-04-26 2019-05-24 N
Provide and implement an infection prevention and control program. Health 2019-04-26 2019-05-24 N