Deficiency Records for Deanwood Rehabilitation and Wellness Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Deanwood Rehabilitation and Wellness 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-06-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-15 | 2023-01-18 | N |
| Report COVID19 data to residents and families. | Health | 2022-12-15 | 2023-01-18 | 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 | 2022-12-15 | 2023-01-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-20 | 2022-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-20 | 2022-09-07 | 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 | 2022-04-20 | 2022-09-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-20 | 2022-09-07 | 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 | 2022-04-20 | 2022-09-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-20 | 2022-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-20 | 2022-09-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-20 | 2022-08-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-20 | 2022-08-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-20 | 2022-08-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-20 | 2022-08-24 | 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 | 2022-04-20 | 2022-08-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-20 | 2022-08-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-20 | 2022-08-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-20 | 2022-08-24 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-20 | 2022-08-24 | 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 | 2022-04-20 | 2022-08-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-20 | 2022-08-24 | 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 | 2022-04-20 | 2022-08-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-04-20 | 2022-08-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-20 | 2022-08-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-20 | 2022-08-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-20 | 2022-08-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-20 | 2022-08-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-20 | 2022-08-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-20 | 2022-08-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-20 | 2022-08-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-20 | 2022-08-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-20 | 2022-08-24 | N |
| Post nurse staffing information every day. | Health | 2022-04-20 | 2022-08-24 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-04-20 | 2022-08-24 | 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 | 2022-04-20 | 2022-08-24 | 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 | 2022-04-20 | 2022-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-20 | 2022-08-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-20 | 2022-08-24 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-04-20 | 2022-08-24 | 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 | 2022-04-20 | 2022-08-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-20 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-20 | 2022-08-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-20 | 2022-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-04 | 2022-08-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-04 | 2022-08-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-05 | 2021-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-05 | 2021-06-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-05 | 2021-06-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-05 | 2021-06-21 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-07 | 2021-05-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-07 | 2021-05-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-07 | 2021-05-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-05-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-05-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-07 | 2021-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-05-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-07-29 | 2020-09-21 | 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 | 2020-07-29 | 2020-09-21 | 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 | 2020-07-29 | 2020-09-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-07-29 | 2020-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-07-29 | 2020-09-21 | 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 | 2020-07-29 | 2020-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-07-29 | 2020-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-07-29 | 2020-09-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-03-26 | 2019-05-17 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-03-26 | 2019-05-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-26 | 2019-05-17 | 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 | 2019-03-26 | 2019-05-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-26 | 2019-05-17 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-26 | 2019-05-17 | 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 | 2019-03-26 | 2019-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-26 | 2019-05-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-26 | 2019-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-26 | 2019-05-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-26 | 2019-05-17 | 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 | 2019-03-26 | 2019-05-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-26 | 2019-05-17 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-26 | 2019-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-26 | 2019-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-26 | 2019-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-26 | 2019-05-17 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-03-26 | 2019-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-26 | 2019-05-17 | 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 | 2019-03-26 | 2019-05-17 | 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 | 2019-03-26 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-26 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-26 | 2019-05-17 | N |
| Keep all essential equipment working safely. | Health | 2019-03-26 | 2019-05-17 | N |
| Meet other general requirements. | Fire Safety | 2019-03-22 | 2019-05-17 | N |
