Deficiency Records for Careage Hills Rehabilitation and Healthcare
Updated as of March 01, 2024
A list of the most recent deficiencies for Careage Hills Rehabilitation and Healthcare. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-12 | 2023-02-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-12 | 2023-01-06 | N |
| Develop a communication plan. | Fire Safety | 2022-12-12 | 2022-12-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-12-12 | 2022-12-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-12 | 2022-12-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-12 | 2022-12-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-12 | 2022-12-14 | 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 | 2022-12-08 | 2022-12-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-08 | 2022-12-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-08 | 2022-12-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-08 | 2022-12-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-08 | 2022-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-12 | 2022-12-13 | 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 | 2022-12-12 | 2022-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-12 | 2022-12-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-12 | 2022-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-12 | 2022-12-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-12 | 2022-12-12 | 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 | 2021-09-30 | 2021-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-10-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-09-30 | 2021-10-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-30 | 2021-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-30 | 2021-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-30 | 2021-10-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-30 | 2021-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-10-14 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-28 | 2021-10-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-28 | 2021-10-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-28 | 2021-10-14 | 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 | 2021-09-28 | 2021-10-14 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-09-28 | 2021-10-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-28 | 2021-10-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-06 | 2019-11-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-06 | 2019-11-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-31 | 2019-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-31 | 2019-11-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-31 | 2019-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-31 | 2019-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-31 | 2019-11-15 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-10-31 | 2019-11-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-31 | 2019-11-15 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-10-31 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-06 | 2019-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-06 | 2019-11-14 | 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 | 2019-11-06 | 2019-11-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-06 | 2019-11-07 | N |
