Deficiency Records for Community Subacute and Transitional Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Community Subacute and Transitional Care 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? |
|---|---|---|---|---|
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-12-16 | 2023-01-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-16 | 2023-01-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-16 | 2023-01-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-16 | 2023-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-16 | 2023-01-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-16 | 2023-01-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-16 | 2023-01-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-16 | 2023-01-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-16 | 2023-01-29 | 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 | 2022-12-16 | 2023-01-29 | 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 | 2022-12-16 | 2023-01-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-16 | 2023-01-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-14 | 2023-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-14 | 2023-01-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-14 | 2021-12-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-21 | 2019-08-27 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-05-21 | 2019-08-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-21 | 2019-08-27 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-05-21 | 2019-08-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-21 | 2019-08-27 | 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 | 2019-05-21 | 2019-08-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-21 | 2019-08-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-21 | 2019-08-27 | 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 | 2019-05-21 | 2019-08-27 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-05-21 | 2019-08-27 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-05-21 | 2019-08-27 | N |
| 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. | Health | 2019-05-21 | 2019-08-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-05-21 | 2019-08-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-05-21 | 2019-08-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-21 | 2019-08-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-21 | 2019-08-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-21 | 2019-08-27 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-05-21 | 2019-08-27 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-21 | 2019-08-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-21 | 2019-08-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-21 | 2019-08-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-19 | 2019-07-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-03-02 | 2018-06-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-02 | 2018-06-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-03-02 | 2018-06-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-02 | 2018-06-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-28 | 2018-04-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-03-28 | 2018-04-18 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-03-28 | 2018-04-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-03-28 | 2018-04-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-28 | 2018-04-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-28 | 2018-04-18 | N |
