Deficiency Records for Community Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Community Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-11 | 2023-06-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-11 | 2023-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-02 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-11 | 2023-06-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-11 | 2023-06-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-11 | 2023-06-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-11 | 2023-06-02 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-11 | 2023-06-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-11 | 2023-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-11 | 2023-06-02 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-11 | 2023-06-02 | N |
| 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 | 2023-05-11 | 2023-06-02 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-05-11 | 2023-06-02 | 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 | 2023-05-11 | 2023-06-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-11 | 2023-06-02 | Y |
| 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 | 2023-06-02 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-11 | 2023-06-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-11 | 2023-06-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-06-02 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-05-11 | 2023-06-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-11 | 2023-06-02 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-16 | 2023-06-02 | 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 | 2023-05-16 | 2023-06-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-30 | 2022-07-29 | 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 | 2022-06-30 | 2022-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-30 | 2022-07-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-07-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-30 | 2022-07-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-30 | 2022-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-10 | 2022-06-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-10 | 2022-06-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-21 | 2022-02-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-21 | 2022-02-10 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| 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 | 2021-12-06 | 2021-12-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-19 | 2021-12-17 | 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 | 2021-11-19 | 2021-12-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-11-19 | 2021-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-19 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-19 | 2021-12-17 | 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 | 2021-11-19 | 2021-12-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-11-19 | 2021-12-17 | N |
| Provide or obtain dental services for each resident. | Health | 2021-11-19 | 2021-12-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-19 | 2021-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2021-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-19 | 2021-12-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-19 | 2021-12-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-19 | 2021-12-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-19 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-25 | 2021-09-24 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-05-16 | 2019-06-10 | 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 | 2019-05-16 | 2019-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-05-16 | 2019-06-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-02 | 2019-05-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-02 | 2019-05-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-02 | 2019-05-01 | 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 | 2019-04-02 | 2019-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-02 | 2019-05-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-04-02 | 2019-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-02 | 2019-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-02 | 2019-05-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-02 | 2019-05-01 | N |
