Deficiency Records for Chowchilla Memorial Healthcare District
Updated as of April 01, 2024
A list of the most recent deficiencies for Chowchilla Memorial Healthcare District. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-18 | 2022-12-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-18 | 2022-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-18 | 2022-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-18 | 2022-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-18 | 2022-12-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-18 | 2022-12-28 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-18 | 2022-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-18 | 2022-12-28 | 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 | 2022-11-18 | 2022-12-28 | 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 | 2022-11-18 | 2022-12-28 | 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 | 2022-11-18 | 2022-12-28 | 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 | 2022-11-18 | 2022-12-28 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-18 | 2022-12-28 | 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 | 2022-11-18 | 2022-12-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-11-18 | 2022-12-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-18 | 2022-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-18 | 2022-12-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-18 | 2022-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-21 | 2022-12-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-29 | 2020-01-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-29 | 2020-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-29 | 2020-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-29 | 2020-01-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-29 | 2020-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-29 | 2020-01-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-07-29 | 2020-01-23 | N |
| Request a waiver if it can't meet the nurse staffing requirements. | Health | 2019-07-29 | 2020-01-23 | 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 | 2019-07-29 | 2020-01-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-29 | 2020-01-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-29 | 2020-01-23 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-07-29 | 2020-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-29 | 2020-01-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-07-29 | 2020-01-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2019-07-29 | 2020-01-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-07-29 | 2020-01-23 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-07-29 | 2020-01-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-29 | 2020-01-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-29 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-29 | 2020-01-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-29 | 2020-01-23 | N |
| Keep all essential equipment working safely. | Health | 2019-07-29 | 2020-01-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-29 | 2020-01-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-05 | 2019-10-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-05 | 2019-10-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-05 | 2019-10-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-05 | 2019-10-10 | 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 | 2018-09-28 | 2019-02-11 | 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 | 2018-09-28 | 2019-02-11 | 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 | 2018-09-28 | 2019-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-28 | 2019-02-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-28 | 2019-02-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-28 | 2019-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-28 | 2019-02-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-28 | 2018-12-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-28 | 2018-12-20 | N |
| Develop a communication plan. | Fire Safety | 2018-11-28 | 2018-12-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-28 | 2018-12-20 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-11-28 | 2018-12-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-28 | 2018-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-28 | 2018-12-20 | N |
