Deficiency Records for Community Care and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Community Care 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-30 | 2023-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-05 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-29 | 2023-09-08 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-08-24 | 2023-09-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-17 | 2023-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-10 | 2022-11-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-02 | 2022-08-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-27 | 2022-06-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-17 | 2022-04-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-13 | 2022-02-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-02-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-11 | 2021-07-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-11 | 2021-07-12 | 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 | 2021-06-11 | 2021-07-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-11 | 2021-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-11 | 2021-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-11 | 2021-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-07-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-11 | 2021-07-12 | 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 | 2021-06-11 | 2021-07-12 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-06-11 | 2021-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-11 | 2021-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-11 | 2021-07-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-06-11 | 2021-07-12 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-15 | 2021-07-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-22 | 2021-05-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-22 | 2021-05-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-08 | 2021-04-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-08 | 2021-04-07 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-03-24 | 2021-03-30 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-03-04 | 2021-03-24 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2019-08-13 | 2019-09-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-08-13 | 2019-09-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-13 | 2019-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-13 | 2019-09-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-18 | 2019-08-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-18 | 2019-08-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-18 | 2019-08-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-18 | 2019-08-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-18 | 2019-08-19 | 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 | 2019-07-18 | 2019-08-19 | 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 | 2019-07-18 | 2019-08-19 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-07-18 | 2019-08-19 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-07-18 | 2019-08-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-18 | 2019-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-08-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-16 | 2018-11-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-16 | 2018-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-16 | 2018-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-13 | 2018-08-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-13 | 2018-08-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-13 | 2018-08-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-13 | 2018-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-13 | 2018-08-22 | 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 | 2018-07-13 | 2018-08-22 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2018-07-13 | 2018-08-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-07-13 | 2018-08-22 | 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 | 2018-07-13 | 2018-08-22 | 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 | 2018-07-13 | 2018-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-13 | 2018-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-13 | 2018-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-13 | 2018-08-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-07-13 | 2018-08-22 | N |
