Deficiency Records for Presbyterian Village North Special Care Ctr
Updated as of March 01, 2023
This is not the most recent data for Presbyterian Village North Special Care Ctr. For the most recent information, click here.
A list of the most recent deficiencies for Presbyterian Village North Special Care Ctr. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-18 | 2022-11-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-15 | 2022-08-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-15 | 2022-08-04 | Y |
| 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 | 2022-07-15 | 2022-08-04 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-02 | 2022-03-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-02 | 2022-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-02 | 2022-03-04 | 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 | 2022-02-02 | 2022-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-02 | 2022-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-02 | 2022-03-04 | 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 | 2021-04-13 | 2021-04-28 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-09-12 | 2019-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-11 | 2019-10-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-11 | 2019-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-11 | 2019-10-04 | 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 | 2019-09-11 | 2019-10-04 | 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 | 2019-09-11 | 2019-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-11 | 2019-10-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-23 | 2018-09-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-23 | 2018-09-25 | 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 | 2018-08-24 | 2018-09-21 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-24 | 2018-09-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-24 | 2018-09-21 | 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 | 2018-08-24 | 2018-09-21 | 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 | 2018-08-24 | 2018-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-24 | 2018-09-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-24 | 2018-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-24 | 2018-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-24 | 2018-08-29 | N |
