A list of the most recent deficiencies for Thunderbolt Health and Rehab. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-18 | 2023-05-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-18 | 2023-05-18 | Y |
| 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 | 2023-04-18 | 2023-05-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-18 | 2023-05-18 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-18 | 2023-05-18 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-18 | 2023-05-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-18 | 2023-05-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-18 | 2023-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-18 | 2023-05-18 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-28 | 2023-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-12 | 2022-06-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-12 | 2022-06-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-06 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-06 | 2021-11-18 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-06 | 2021-11-18 | Y |
| Report COVID19 data to residents and families. | Health | 2021-10-06 | 2021-11-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-06 | 2021-11-18 | Y |
| 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 | 2021-10-06 | 2021-11-18 | Y |
| 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 | 2021-06-11 | 2021-08-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-11 | 2021-08-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-11 | 2021-07-21 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-06-11 | 2021-07-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-11 | 2021-07-21 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-11 | 2021-07-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-11 | 2021-07-21 | N |
| 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 | 2021-06-11 | 2021-07-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-11 | 2021-07-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-06-11 | 2021-07-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-11 | 2021-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-11 | 2021-07-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-11 | 2021-07-21 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-06-11 | 2021-07-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-11 | 2021-07-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-11 | 2021-07-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-08 | 2021-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-08 | 2021-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-08 | 2021-07-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-19 | 2021-07-03 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-05-19 | 2021-07-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-24 | 2018-10-08 | 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 | 2018-08-24 | 2018-10-08 | 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 | 2018-08-24 | 2018-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-24 | 2018-10-08 | 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 | 2018-08-24 | 2018-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-24 | 2018-10-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-08-21 | 2018-10-08 | N |
