Deficiency Records for Englewood Post Acute and Rehabilitation
Updated as of June 01, 2021
This is not the most recent data for Englewood Post Acute and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Englewood Post Acute and Rehabilitation. 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 basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-04-07 | 2021-04-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-11-12 | 2020-12-14 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-02 | 2020-10-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-09-02 | 2020-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-02 | 2020-10-12 | 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 | 2020-09-02 | 2020-10-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-02 | 2020-10-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-02 | 2020-10-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-09-02 | 2020-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-09-02 | 2020-09-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-09-02 | 2020-09-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-09-02 | 2020-09-03 | N |
| 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 | 2020-03-10 | 2020-04-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-10 | 2020-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-10 | 2020-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-10 | 2020-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-10 | 2020-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-10 | 2020-04-20 | N |
| 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 | 2019-07-25 | 2019-08-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-25 | 2019-08-29 | Y |
| 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 | 2019-03-29 | 2019-04-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-29 | 2019-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-05 | 2019-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-29 | 2019-03-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-29 | 2019-03-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-29 | 2019-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-29 | 2019-03-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-05 | 2019-03-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-05 | 2019-03-25 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-03-05 | 2019-03-25 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-03-05 | 2019-03-25 | 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 | 2018-01-29 | 2018-03-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-21 | 2018-03-12 | N |
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2018-01-29 | 2018-02-26 | N |
| 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 | 2018-01-29 | 2018-02-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-01-29 | 2018-02-26 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-01-29 | 2018-02-26 | N |
| Provide activities to meet all resident's needs. | Health | 2018-01-29 | 2018-02-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-29 | 2018-02-26 | 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 | 2018-01-29 | 2018-02-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-01-29 | 2018-02-26 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-01-29 | 2018-02-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-29 | 2018-02-26 | N |
