Deficiency Records for Kentmere Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Kentmere Rehabilitation and Healthcare Center. 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-12 | 2023-12-13 | 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 | 2023-10-12 | 2023-12-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-12 | 2023-12-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-12 | 2023-12-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-10-12 | 2023-12-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-12 | 2023-12-13 | 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 | 2023-10-12 | 2023-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-12 | 2023-12-13 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-10-12 | 2023-12-13 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-10-12 | 2023-12-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-12 | 2023-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-25 | 2022-06-03 | Y |
| 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 | 2022-04-25 | 2022-06-03 | 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 | 2022-04-25 | 2022-04-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-09 | 2022-01-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-09 | 2022-01-07 | 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 | 2021-12-09 | 2022-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-09 | 2022-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-12-09 | 2022-01-07 | 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 | 2021-12-09 | 2022-01-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-09 | 2022-01-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-07 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-09 | 2022-01-07 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-12-09 | 2022-01-07 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-12-09 | 2022-01-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-26 | 2021-09-30 | 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 | 2021-08-26 | 2021-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-30 | 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 | 2020-01-21 | 2020-03-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-21 | 2020-03-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-21 | 2020-03-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-21 | 2020-03-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-21 | 2020-03-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-21 | 2020-03-09 | 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 | 2020-01-21 | 2020-03-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-21 | 2020-02-13 | N |
