A list of the most recent deficiencies for O'connor 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-04 | 2023-05-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-04-04 | 2023-05-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-04-04 | 2023-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-04 | 2023-05-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-23 | 2023-04-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-23 | 2023-04-24 | 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 | 2023-03-23 | 2023-04-24 | 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 | 2023-03-23 | 2023-04-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-03-23 | 2023-04-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-23 | 2023-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-04-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-23 | 2023-04-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-23 | 2023-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-23 | 2023-04-21 | 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 | 2023-03-23 | 2023-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-24 | 2019-11-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-24 | 2019-11-12 | N |
