Deficiency Records for Harcourt Terrace Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Harcourt Terrace Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-16 | 2024-01-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-01-16 | 2024-01-18 | N |
| Develop a communication plan. | Fire Safety | 2024-01-16 | 2024-01-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-01-16 | 2024-01-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-16 | 2024-01-18 | 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 | 2024-01-16 | 2024-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-16 | 2024-01-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-11 | 2024-01-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-11 | 2024-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-11 | 2024-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-11 | 2024-01-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-11 | 2024-01-05 | 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 | 2023-12-11 | 2024-01-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-21 | 2023-08-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-03 | 2022-11-25 | 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 | 2022-11-03 | 2022-11-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-03 | 2022-11-25 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-09-26 | 2022-10-20 | 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 | 2022-09-26 | 2022-10-20 | 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 | 2022-09-26 | 2022-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-26 | 2022-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-26 | 2022-10-20 | 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 | 2022-09-26 | 2022-10-20 | N |
| 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 | 2022-09-26 | 2022-10-20 | 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 | 2022-09-26 | 2022-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-26 | 2022-10-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-26 | 2022-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-01-29 | 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 | 2021-09-23 | 2021-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-23 | 2021-10-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-23 | 2021-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-23 | 2021-10-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-13 | 2021-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-13 | 2021-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-03 | 2021-06-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-03 | 2021-06-23 | Y |
