A list of the most recent deficiencies for Imperial Manor. 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 residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-02-23 | 2024-03-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-03-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-10-10 | Y |
| 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 | 2023-05-12 | 2023-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-06-15 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-05-12 | 2023-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-06-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-06-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-22 | 2022-01-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-16 | 2021-07-16 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-23 | 2019-06-03 | 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 | 2019-04-23 | 2019-06-03 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-23 | 2019-06-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-12 | 2019-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-12 | 2019-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-12 | 2019-04-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-12 | 2019-04-16 | 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 | 2019-03-12 | 2019-04-16 | 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 | 2019-03-12 | 2019-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-12 | 2019-04-16 | 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 | 2019-03-12 | 2019-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-12 | 2019-04-16 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-03-12 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-03-12 | Not Fixed | N |
