Russell Regional Hospital Ltcu

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Construction Deficiencies

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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.

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

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

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.

Smoke Deficiencies

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

Smoke Deficiencies

Properly provide smoke detection systems in areas open to corridors.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

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.

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.