A list of the most recent deficiencies for Hartley Nursing and Rehab. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-25 | 2019-11-08 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-09-25 | 2019-10-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-09-25 | 2019-10-24 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2019-08-05 | 2019-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-05 | 2019-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-05 | 2019-10-11 | 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 | 2019-08-05 | 2019-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-05 | 2019-10-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-05 | 2019-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-05 | 2019-10-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-25 | 2019-09-30 | 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 | 2019-09-25 | 2019-09-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-25 | 2019-09-25 | 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 | 2018-04-26 | 2018-06-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-04-26 | 2018-06-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-26 | 2018-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-26 | 2018-06-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-26 | 2018-06-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-04-26 | 2018-06-26 | 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 | 2018-04-26 | 2018-06-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-26 | 2018-06-26 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2018-04-26 | 2018-06-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-26 | 2018-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-26 | 2018-06-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-05-03 | 2018-06-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-03 | 2018-05-31 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-01-20 | 2017-02-10 | N |
| Provide housekeeping and maintenance services. | Health | 2017-01-20 | 2017-02-10 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-01-20 | 2017-02-10 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-20 | 2017-02-10 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-01-20 | 2017-02-10 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-01-20 | 2017-02-10 | N |
| Provide or obtain dental services for each resident. | Health | 2017-01-20 | 2017-02-10 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-20 | 2017-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-19 | 2017-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-01-19 | 2017-02-01 | N |
| Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Fire Safety | 2017-01-19 | 2017-02-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2017-01-19 | 2017-02-01 | N |
