A list of the most recent deficiencies for Alcott Rehabilitation Hospital. 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | 2024-02-09 | Y |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-12-14 | 2024-01-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2024-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-14 | 2023-12-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-14 | 2023-12-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-02 | 2023-11-30 | 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 | 2023-11-02 | 2023-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-02 | 2023-11-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-02 | 2023-11-30 | 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 | 2023-11-02 | 2023-11-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-02 | 2023-11-30 | N |
| Post nurse staffing information every day. | Health | 2023-11-02 | 2023-11-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-02 | 2023-11-30 | 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 | 2023-11-02 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-11-30 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-02 | 2023-11-30 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Meet other general requirements. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-26 | 2023-11-22 | Y |
| 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 | 2023-07-07 | 2023-08-03 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-07 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-07 | 2023-08-03 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-05 | 2023-05-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2022-12-16 | 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 | 2022-11-17 | 2022-12-16 | 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 | 2022-11-17 | 2022-12-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-17 | 2022-12-16 | 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 | 2022-11-17 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-17 | 2022-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2022-12-16 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-11-17 | 2022-12-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-11-17 | 2022-12-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-17 | 2022-12-16 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-17 | 2022-12-16 | 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 | 2022-11-17 | 2022-12-16 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-17 | 2022-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-08 | 2022-03-18 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-03-04 | 2022-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-03-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-20 | 2020-02-13 | 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 | 2020-01-20 | 2020-02-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-20 | 2020-02-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-20 | 2020-02-13 | 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 | 2020-01-20 | 2020-02-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-20 | 2020-02-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-20 | 2020-02-13 | N |
| Post nurse staffing information every day. | Health | 2020-01-20 | 2020-02-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-20 | 2020-02-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-20 | 2020-02-13 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-20 | 2020-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-20 | 2020-02-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-22 | 2020-01-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-01-22 | 2020-01-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-22 | 2020-01-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-01-20 | Not Fixed | N |
