A list of the most recent deficiencies for Embassy Rehab and 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-18 | 2024-02-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-18 | 2024-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-18 | 2024-02-18 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-05-04 | 2023-06-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-04 | 2023-06-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-04 | 2023-06-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-04 | 2023-06-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-04 | 2023-06-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-04 | 2023-06-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-04 | 2023-06-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-04 | 2023-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-04 | 2023-06-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-05-04 | 2023-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-04 | 2023-06-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-04 | 2023-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-04 | 2023-06-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-05-04 | 2023-06-20 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-05-04 | 2023-06-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-04 | 2023-06-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-05-04 | 2023-06-20 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-04 | 2023-06-20 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-04 | 2023-06-20 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-04 | 2023-06-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-04 | 2023-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-06-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-04 | 2023-06-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-04 | 2023-06-20 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-05-04 | 2023-06-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-06-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-24 | 2023-05-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-24 | 2023-05-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-24 | 2023-04-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-04-24 | 2023-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-24 | 2023-04-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-26 | 2022-06-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-26 | 2022-06-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-26 | 2022-05-26 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-04-26 | 2022-05-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-26 | 2022-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-26 | 2022-05-26 | N |
| Post nurse staffing information every day. | Health | 2022-04-26 | 2022-05-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-26 | 2022-05-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-26 | 2022-05-26 | 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 | 2022-04-26 | 2022-05-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-26 | 2022-05-26 | 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 | 2022-04-26 | 2022-05-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-26 | 2022-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-26 | 2022-05-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-26 | 2022-05-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-26 | 2022-05-26 | Y |
| 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 | 2022-04-26 | 2022-05-26 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-26 | 2022-05-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-26 | 2022-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-26 | 2022-05-26 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-15 | 2022-05-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-15 | 2022-05-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-15 | 2022-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-15 | 2022-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-15 | 2022-05-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-15 | 2022-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-15 | 2022-05-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-15 | 2022-05-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-15 | 2022-04-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-15 | 2022-04-26 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-04-15 | 2022-04-24 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-04-15 | 2022-04-15 | 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 | 2019-09-18 | 2019-10-18 | 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 | 2019-09-18 | 2019-10-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-18 | 2019-10-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-18 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-18 | 2019-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-19 | 2019-10-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-19 | 2019-10-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-19 | 2019-10-02 | 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 | 2019-09-19 | 2019-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-19 | 2019-09-21 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-09-18 | 2019-09-18 | N |
