Deficiency Records for Health and Rehabilitation Centre at Dolphins View
Updated as of April 01, 2024
A list of the most recent deficiencies for Health and Rehabilitation Centre at Dolphins View. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-05-15 | 2023-06-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-15 | 2023-06-14 | 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 | 2023-05-15 | 2023-06-12 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-05-15 | 2023-06-12 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-31 | 2023-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-31 | 2023-03-06 | 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 | 2023-02-02 | 2023-03-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | 2023-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-02 | 2023-03-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-02 | 2023-03-04 | 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 | 2023-02-02 | 2023-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-02 | 2023-03-04 | 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 | 2023-02-02 | 2023-03-04 | 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 | 2023-02-02 | 2023-03-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-02 | 2023-03-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-02-02 | 2023-03-04 | 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 | 2022-02-03 | 2022-03-03 | Y |
| 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 | 2022-02-03 | 2022-03-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-23 | 2021-07-23 | 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 | 2021-06-23 | 2021-07-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-23 | 2021-07-23 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-23 | 2021-07-23 | 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 | 2021-06-23 | 2021-07-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-23 | 2021-07-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-23 | 2021-07-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-23 | 2021-07-23 | 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 | 2021-06-23 | 2021-07-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-23 | 2021-07-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-22 | 2021-07-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Develop a communication plan. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-24 | 2019-10-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-27 | 2019-10-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-27 | 2019-10-10 | 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 | 2019-09-27 | 2019-10-10 | 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 | 2019-09-27 | 2019-10-10 | N |
