Deficiency Records for Gladstone Sub-Acute and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Gladstone Sub-Acute and Rehab 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 policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-17 | 2024-02-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-21 | 2024-01-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-21 | 2024-01-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2023-12-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-11-03 | 2023-12-03 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-10-04 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-09 | 2023-08-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-25 | 2023-08-16 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-03-22 | 2023-04-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-28 | 2023-03-17 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-11-29 | 2022-12-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-09-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-07-22 | 2022-09-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-08 | 2022-07-06 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-28 | 2022-06-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-28 | 2022-06-20 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-08 | 2022-04-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-02-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-12-21 | 2022-02-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-13 | 2022-01-25 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-13 | 2022-01-25 | 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 | 2021-12-13 | 2022-01-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-13 | 2022-01-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-13 | 2022-01-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-13 | 2022-01-25 | 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 | 2021-12-13 | 2022-01-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-13 | 2022-01-25 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-13 | 2022-01-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-13 | 2022-01-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2022-01-25 | 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 | 2021-12-13 | 2022-01-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-13 | 2022-01-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-13 | 2022-01-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-13 | 2022-01-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-13 | 2022-01-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-13 | 2022-01-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-13 | 2022-01-25 | 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 | 2021-12-13 | 2022-01-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-12-13 | 2022-01-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-12-13 | 2022-01-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-13 | 2022-01-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-13 | 2022-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2022-01-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-13 | 2022-01-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-24 | 2021-10-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-24 | 2021-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-24 | 2021-10-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-24 | 2021-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-03 | 2021-10-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-03 | 2021-10-20 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-09-03 | 2021-10-20 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-03 | 2021-10-20 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-03 | 2021-10-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-20 | 2019-10-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-20 | 2019-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-20 | 2019-10-22 | 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 | 2019-09-20 | 2019-10-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-20 | 2019-10-22 | 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 | 2019-09-20 | 2019-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-20 | 2019-10-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-20 | 2019-10-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-20 | 2019-10-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-20 | 2019-10-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-20 | 2019-10-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-20 | 2019-10-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-20 | 2019-10-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-20 | 2019-10-22 | 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 | 2019-09-20 | 2019-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-20 | 2019-10-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-20 | 2019-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-20 | 2019-10-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-20 | 2019-10-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-20 | 2019-10-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-20 | 2019-10-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-23 | 2019-10-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-10-15 | 2018-12-18 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-10-15 | 2018-12-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-15 | 2018-12-18 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-15 | 2018-12-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-15 | 2018-12-18 | 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 | 2018-10-15 | 2018-12-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-15 | 2018-12-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-15 | 2018-12-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-15 | 2018-12-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-15 | 2018-12-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-15 | 2018-12-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-15 | 2018-12-18 | 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 | 2018-10-15 | 2018-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-15 | 2018-12-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-15 | 2018-12-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-15 | 2018-12-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-18 | 2018-11-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-18 | 2018-11-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-10-18 | 2018-11-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-18 | 2018-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-18 | 2018-11-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-18 | 2018-11-29 | N |
