Deficiency Records for Family Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Family Health 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? |
---|---|---|---|---|
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 | 2022-10-24 | 2022-11-04 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-24 | 2022-11-04 | N |
Keep residents' personal and medical records private and confidential. | Health | 2022-08-31 | 2022-09-25 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-31 | 2022-09-25 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-31 | 2022-09-25 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-31 | 2022-09-25 | 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 | 2022-08-31 | 2022-09-25 | N |
Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-09-25 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-19 | 2021-08-06 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-19 | 2021-08-06 | Y |
Respond appropriately to all alleged violations. | Health | 2021-07-19 | 2021-08-06 | Y |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-03 | 2021-03-10 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-03 | 2021-03-10 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-03 | 2021-03-10 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-03 | 2021-03-10 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-03 | 2021-03-10 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-03 | 2021-03-10 | 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 | 2021-01-07 | 2021-01-30 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-25 | 2019-08-05 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-25 | 2019-08-05 | 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 | 2019-06-25 | 2019-08-05 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-25 | 2019-08-05 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-25 | 2019-08-05 | 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 | 2019-06-25 | 2019-08-05 | N |
Address patient/client population and determine types of services needed. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Create arrangements with other facilities to receive patients. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Establish methods for sharing information. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Provide family notifications of emergency plan. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-03 | 2019-04-18 | N |