A list of the most recent deficiencies for Self Skilled Nursing and Rehab. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-03-18 | 2021-04-22 | N |
| 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 | 2021-03-18 | 2021-04-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-18 | 2021-04-22 | N |
| 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. | Health | 2021-03-18 | 2021-04-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-18 | 2021-04-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-18 | 2021-04-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-18 | 2021-04-22 | 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 | 2021-03-18 | 2021-04-22 | 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 | 2021-03-18 | 2021-04-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-18 | 2021-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-04-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-24 | 2021-04-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-24 | 2021-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-24 | 2021-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-24 | 2021-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-24 | 2021-04-05 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-03-24 | 2021-04-05 | N |
| 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 | 2019-02-07 | 2019-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-13 | N |
| Dispose of garbage and refuse properly. | Health | 2019-02-07 | 2019-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-07 | 2019-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-12 | 2019-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-08 | 2018-03-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-03-08 | 2018-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-08 | 2018-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-08 | 2018-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-15 | 2018-03-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-03-15 | 2018-03-20 | N |
