Deficiency Records for Childrens Hc Org No Ca -Pediatric Hospital D/p Snf
Updated as of March 01, 2024
A list of the most recent deficiencies for Childrens Hc Org No Ca -Pediatric Hospital D/p 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-19 | 2022-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-08-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-08 | 2022-07-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-11 | 2022-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-11 | 2022-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-11 | 2022-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-08 | 2022-07-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-20 | 2021-08-04 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-10 | 2019-12-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-22 | 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 | 2019-10-31 | 2019-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-31 | 2019-11-22 | 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 | 2019-10-31 | 2019-11-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2019-11-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-10-31 | 2019-11-22 | N |
| Keep all essential equipment working safely. | Health | 2019-10-31 | 2019-11-22 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-22 | 2019-06-19 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-27 | 2019-04-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-27 | 2019-04-10 | N |
