Deficiency Records for The Rehabilitation Center of North Hills
Updated as of April 01, 2024
A list of the most recent deficiencies for The Rehabilitation Center of North Hills. 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 for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-02-23 | 2024-03-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-23 | 2024-03-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-11 | 2024-02-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-11 | 2024-02-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-11 | 2024-02-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-22 | 2023-10-15 | Y |
| 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 | 2023-09-22 | 2023-10-15 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-09-22 | 2023-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-25 | 2023-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-11 | 2023-09-04 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-11 | 2023-06-10 | Y |
| 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 | 2023-05-11 | 2023-06-10 | Y |
| Provide appropriate foot care. | Health | 2023-05-11 | 2023-06-10 | Y |
| 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 | 2023-05-11 | 2023-06-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-11 | 2023-06-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-11 | 2023-06-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-19 | 2023-05-18 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-19 | 2023-05-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-26 | 2023-05-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-07 | 2023-04-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-07 | 2023-04-06 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-07 | 2023-04-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-07 | 2023-04-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-14 | 2023-01-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-31 | 2023-01-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-31 | 2023-01-20 | 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 | 2022-12-31 | 2023-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-06 | 2022-12-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-28 | 2022-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-03 | 2022-08-11 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-18 | 2022-06-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-02-18 | 2022-05-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-18 | 2022-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-18 | 2022-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-18 | 2022-05-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-18 | 2022-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-20 | 2022-03-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-18 | 2022-03-17 | 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 | 2022-02-18 | 2022-03-17 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-18 | 2022-03-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-02-18 | 2022-03-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-18 | 2022-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-18 | 2022-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-18 | 2022-03-17 | 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 | 2022-02-18 | 2022-03-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-02-18 | 2022-03-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-18 | 2022-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-03-17 | 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 | 2022-02-18 | 2022-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-12-26 | 2022-01-04 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-10-21 | 2021-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-14 | 2021-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-27 | 2021-10-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-04 | 2021-09-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-04 | 2021-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-29 | 2021-08-18 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-29 | 2021-08-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-29 | 2021-08-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-29 | 2021-08-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-29 | 2021-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-14 | 2021-07-20 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-07-13 | 2021-07-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-16 | 2021-06-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-16 | 2021-06-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-16 | 2021-06-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-04-27 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-12-03 | 2019-12-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-03 | 2019-12-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-03 | 2019-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-03 | 2019-12-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-12-03 | 2019-12-27 | 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 | 2019-12-03 | 2019-12-27 | 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 | 2019-12-03 | 2019-12-27 | 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 | 2019-12-03 | 2019-12-27 | 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 | 2019-12-03 | 2019-12-27 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-12-03 | 2019-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-03 | 2019-12-27 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-12-03 | 2019-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-03 | 2019-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-25 | 2019-12-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-25 | 2019-12-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-25 | 2019-12-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-11-30 | 2018-12-27 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-30 | 2018-12-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-30 | 2018-12-27 | N |
| 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 | 2018-11-30 | 2018-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-30 | 2018-12-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-30 | 2018-12-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-11-30 | 2018-12-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-30 | 2018-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-30 | 2018-12-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-30 | 2018-12-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-30 | 2018-12-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-30 | 2018-12-27 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-11-30 | 2018-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-30 | 2018-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-30 | 2018-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-28 | 2018-12-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-28 | 2018-12-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-28 | 2018-12-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-03 | 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 | 2018-11-30 | Not Fixed | N |
