A list of the most recent deficiencies for Aledo Rehab and Health Care 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-29 | 2024-03-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-29 | 2024-03-19 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-02-29 | 2024-03-19 | 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 | 2024-02-18 | 2024-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-11 | 2024-02-24 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-01-11 | 2024-01-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-01-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-01-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-01-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-14 | 2023-08-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-14 | 2023-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-14 | 2023-08-25 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-16 | 2023-07-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-16 | 2023-07-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-16 | 2023-07-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-16 | 2023-07-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-16 | 2023-07-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-15 | 2023-06-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-15 | 2023-06-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-15 | 2023-06-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-15 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-06-30 | 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 | 2023-06-15 | 2023-06-30 | 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 | 2023-06-15 | 2023-06-30 | 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 | 2023-06-15 | 2023-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-06-30 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-15 | 2023-06-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-01 | 2023-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-03 | 2022-11-18 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-03 | 2022-11-18 | 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 | 2022-11-03 | 2022-11-18 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-09-21 | 2022-09-28 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-18 | 2022-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-18 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-18 | 2022-05-27 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-05-18 | 2022-05-27 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-04-13 | 2022-05-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-13 | 2022-05-04 | 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 | 2022-04-13 | 2022-05-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-27 | 2022-05-02 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-04-14 | 2022-05-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-14 | 2022-05-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-20 | 2022-04-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-20 | 2022-04-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-31 | 2022-02-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-31 | 2022-02-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-31 | 2022-02-11 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-13 | 2021-08-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-13 | 2021-08-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-30 | 2021-08-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-30 | 2021-08-20 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-03-03 | 2021-05-14 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-03-03 | 2021-05-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-03 | 2021-03-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-02-25 | 2021-03-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-03 | 2021-03-21 | 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 | 2021-02-25 | 2021-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-25 | 2021-03-19 | 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 | 2021-02-25 | 2021-03-19 | N |
| Provide activities to meet all resident's needs. | Health | 2021-02-25 | 2021-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-25 | 2021-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-25 | 2021-03-19 | 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 | 2021-02-25 | 2021-03-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-02-25 | 2021-03-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-02-25 | 2021-03-19 | 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 | 2021-02-25 | 2021-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-25 | 2021-03-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Develop a communication plan. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-03 | 2021-03-19 | 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 | 2021-03-03 | 2021-03-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-03 | 2021-03-19 | 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 | 2021-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-03 | 2021-03-19 | N |
