Deficiency Records for Alcott Rehabilitation Hospital
Updated as of September 01, 2022
This is not the most recent data for Alcott Rehabilitation Hospital. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-02-21 | 2021-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-04 | 2021-01-20 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-07-27 | 2020-08-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2020-07-27 | 2020-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-07-27 | 2020-08-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-24 | 2020-07-09 | 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 | Y |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-18 | 2019-11-04 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-10-18 | 2019-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-28 | 2019-02-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-28 | 2019-02-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-28 | 2019-02-21 | 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 | 2019-01-28 | 2019-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-28 | 2019-02-21 | 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 | 2019-01-28 | 2019-02-21 | 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 | 2019-01-28 | 2019-02-21 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-28 | 2019-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-28 | 2019-02-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-01-23 | 2019-02-15 | 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 | 2019-01-23 | 2019-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-18 | 2018-03-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-02-18 | 2018-03-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-02-18 | 2018-03-16 | 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 | 2018-02-18 | 2018-03-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-18 | 2018-03-16 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2018-02-18 | 2018-03-16 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Develop a communication plan. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-19 | 2018-03-16 | 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 | 2018-02-19 | 2018-03-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-02-19 | 2018-03-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-01-20 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-01-28 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-02-18 | Not Fixed | N |
