A list of the most recent deficiencies for Salmon Brook Rehab and Nursing. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-08 | 2023-07-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-08 | 2023-07-14 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-06-08 | 2023-07-14 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-06-08 | 2023-07-14 | 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 | 2023-06-08 | 2023-07-14 | 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 | 2023-06-08 | 2023-07-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-08 | 2023-07-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-08 | 2023-07-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-08 | 2023-07-14 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-08 | 2023-07-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-08 | 2023-07-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-08 | 2023-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-07-14 | 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 | 2023-06-08 | 2023-07-14 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-08 | 2023-07-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-08 | 2023-07-14 | N |
| Post nurse staffing information every day. | Health | 2023-06-08 | 2023-07-14 | N |
| 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 | 2023-06-08 | 2023-07-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-08 | 2023-07-14 | 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 | 2023-06-08 | 2023-07-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-08 | 2023-07-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-08 | 2023-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-07-14 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-08 | 2023-07-14 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-06-08 | 2023-07-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-08 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-07-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-08 | 2023-07-14 | N |
| Report COVID19 data to residents and families. | Health | 2023-06-08 | 2023-07-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-08 | 2023-07-14 | N |
| Keep all essential equipment working safely. | Health | 2023-06-08 | 2023-07-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-30 | 2023-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-04-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-22 | 2023-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-22 | 2023-04-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-01 | 2022-12-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-01 | 2022-12-20 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-12-01 | 2022-12-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-05 | 2022-10-28 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-03 | 2021-05-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-03 | 2021-05-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-03 | 2021-05-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-03 | 2021-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-03 | 2021-05-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-10 | 2021-04-19 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-10 | 2021-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-10 | 2021-04-19 | 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 | 2021-03-10 | 2021-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-10 | 2021-04-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-28 | 2019-10-02 | 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 | 2019-07-03 | 2019-08-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-03 | 2019-08-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-03 | 2019-08-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-07-03 | 2019-08-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-03 | 2019-08-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-03 | 2019-08-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-03 | 2019-08-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-03 | 2019-08-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-03 | 2019-08-14 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-07-03 | 2019-08-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-03 | 2019-08-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-03 | 2019-08-14 | 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 | 2019-07-03 | 2019-08-14 | 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 | 2019-07-03 | 2019-08-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-07-03 | 2019-08-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-07-03 | 2019-08-14 | N |
| 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 | 2019-07-03 | 2019-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-03 | 2019-08-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-03 | 2019-08-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-28 | 2019-08-11 | N |
