Deficiency Records for Estrella Health and Rehabilitation Center
Updated as of July 01, 2021
This is not the most recent data for Estrella Health and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Estrella Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-12 | 2021-05-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-12 | 2021-05-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-12 | 2021-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-12 | 2021-05-04 | 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 | 2021-04-09 | 2021-05-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-09 | 2021-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-09 | 2021-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-09 | 2021-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-09 | 2021-05-03 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-01-04 | 2021-02-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-01-04 | 2021-02-24 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-01-04 | 2021-02-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-01-04 | 2021-02-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-01-04 | 2021-02-24 | Y |
| Post nurse staffing information every day. | Health | 2021-01-21 | 2021-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-23 | 2020-10-12 | N |
| Report COVID19 data to residents and families. | Health | 2020-08-26 | 2020-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-07-16 | 2020-08-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-08-02 | 2019-10-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-02 | 2019-10-16 | N |
| 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. | Health | 2019-08-02 | 2019-10-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-02 | 2019-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-02 | 2019-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-02 | 2019-10-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-02 | 2019-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-02 | 2019-10-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-02 | 2019-10-16 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-02 | 2019-09-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-02 | 2019-09-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-02 | 2019-09-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-02 | 2019-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-02 | 2019-09-06 | N |
| 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. | Health | 2018-05-11 | 2018-06-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-11 | 2018-06-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-11 | 2018-06-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-05-11 | 2018-06-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-11 | 2018-06-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-05-11 | 2018-06-25 | 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 | 2018-05-11 | 2018-06-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-11 | 2018-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-11 | 2018-06-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-22 | 2018-06-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-05-22 | 2018-06-18 | N |
