Pope Nursing Home

Nutrition and Dietary Deficiencies

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.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Emergency Preparedness Deficiencies

Address patient/client population and determine types of services needed.

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

Emergency Preparedness Deficiencies

Establish procedures for tracking staff and patients during an emergency.

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

Emergency Preparedness Deficiencies

Establish policies and procedures for sheltering.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Egress Deficiencies

Have correct number of accessible exits for each story.

Egress Deficiencies

Have exits that are accessible at all times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Meet other general requirements that are deficient.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Egress Deficiencies

Have correct number of accessible exits for each story.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Egress Deficiencies

Have correct number of accessible exits for each story.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.