Deficiency Records for Dept of State Hospitals - Metropolitan Snf
Updated as of April 01, 2024
A list of the most recent deficiencies for Dept of State Hospitals - Metropolitan Snf. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-01 | 2024-01-09 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-01 | 2024-01-09 | 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 | 2023-12-01 | 2024-01-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-01 | 2024-01-09 | 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 | 2023-12-01 | 2024-01-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2024-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2024-01-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-01 | 2024-01-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2024-01-09 | 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 | 2023-12-01 | 2024-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2024-01-09 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-01 | 2024-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-12-01 | 2024-01-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-01 | 2024-01-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-06 | 2023-12-26 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-12-06 | 2023-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2023-12-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-06 | 2023-12-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-06 | 2023-12-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-12 | 2023-08-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-12 | 2023-08-04 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-05-09 | 2023-05-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-09 | 2023-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-07 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-04 | 2021-09-02 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-04 | 2021-09-02 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-04 | 2021-09-02 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-04 | 2021-09-02 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-08-04 | 2021-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-09 | 2021-08-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-02 | 2021-08-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-02 | 2021-08-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-02 | 2021-08-10 | 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 | 2021-07-02 | 2021-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-08-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-07-02 | 2021-08-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-02 | 2021-08-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-02 | 2021-08-10 | 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 | 2021-07-02 | 2021-08-10 | 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 | 2021-07-02 | 2021-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-02 | 2021-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-02 | 2021-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-02 | 2021-08-10 | N |
| Keep all essential equipment working safely. | Health | 2021-07-02 | 2021-08-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-02 | 2021-08-10 | 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 | 2021-07-07 | 2021-08-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-07 | 2021-08-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-10 | 2020-02-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-10 | 2020-02-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-01-10 | 2020-02-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-10 | 2020-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-10 | 2020-02-18 | 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 | 2020-01-10 | 2020-02-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-10 | 2020-02-18 | 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 | 2020-01-10 | 2020-02-18 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-01-10 | 2020-02-18 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-10 | 2020-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-10 | 2020-02-18 | N |
| Keep all essential equipment working safely. | Health | 2020-01-10 | 2020-02-18 | N |
