A list of the most recent deficiencies for Thomas Rest Haven. 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? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-02 | 2023-09-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-02 | 2023-09-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-02 | 2023-09-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-09-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-27 | 2023-08-19 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-07-27 | 2023-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-27 | 2023-08-19 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-07-27 | 2023-08-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-06 | 2022-04-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-06 | 2022-04-29 | 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 | 2022-04-06 | 2022-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-06 | 2022-04-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-06 | 2022-04-29 | Y |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-04-04 | 2022-04-12 | 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 | 2022-04-04 | 2022-04-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-04 | 2022-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-04 | 2022-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-21 | 2020-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-21 | 2020-10-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-10-21 | 2020-10-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-10-21 | 2020-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-18 | 2020-04-10 | 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 | 2020-03-18 | 2020-04-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-18 | 2020-04-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-18 | 2020-04-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-18 | 2020-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-18 | 2020-04-10 | 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 | 2020-03-18 | 2020-04-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-03-18 | 2020-04-10 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-03-18 | 2020-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-18 | 2020-04-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-18 | 2020-04-10 | N |
