Deficiency Records for The Nursing and Rehab Center at Stadium Place
Updated as of March 01, 2024
A list of the most recent deficiencies for The Nursing and Rehab Center at Stadium Place. 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 an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Develop a communication plan. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-01 | 2023-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-23 | 2023-04-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-23 | 2023-04-10 | 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 | 2023-01-23 | 2023-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-23 | 2023-04-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-23 | 2023-04-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-23 | 2023-04-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-23 | 2023-04-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-23 | 2023-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-23 | 2023-04-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-23 | 2023-04-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-23 | 2023-04-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-01 | 2023-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-01 | 2023-04-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-01 | 2023-04-07 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-02-01 | 2023-04-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-01 | 2023-04-07 | N |
| Meet other general requirements. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-01 | 2023-03-16 | 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 | 2023-02-01 | 2023-03-16 | 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 | 2023-02-01 | 2023-03-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-02-01 | 2023-03-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-23 | 2023-03-07 | N |
| 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 | 2023-01-23 | 2023-03-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-23 | 2023-03-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-23 | 2023-03-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-23 | 2023-03-07 | 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 | 2023-01-23 | 2023-03-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-23 | 2023-03-07 | N |
| 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 | 2023-01-23 | 2023-03-07 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-23 | 2023-03-07 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-01-23 | 2023-03-07 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-01-23 | 2023-03-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-23 | 2023-03-07 | 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 | 2023-01-23 | 2023-03-07 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-01-23 | 2023-03-07 | 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 | 2023-01-23 | 2023-03-07 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-01-23 | 2023-03-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-23 | 2023-03-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-23 | 2023-03-07 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-01-23 | 2023-03-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-23 | 2023-03-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-23 | 2023-03-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-16 | 2019-06-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-16 | 2019-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-16 | 2019-05-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-11 | 2019-05-08 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-11 | 2019-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-11 | 2019-05-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-11 | 2019-05-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-11 | 2019-05-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-11 | 2019-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-11 | 2019-05-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-11 | 2019-05-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-03-11 | 2019-05-08 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2019-03-11 | 2019-05-08 | 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 | 2019-03-11 | 2019-05-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-11 | 2019-05-08 | 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 | 2019-03-11 | 2019-05-08 | 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 | 2019-03-11 | 2019-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-11 | 2019-05-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-11 | 2019-05-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-11 | 2019-05-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-16 | 2019-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-16 | 2019-04-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-16 | 2019-04-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-16 | 2019-04-17 | 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 | 2017-10-13 | 2017-11-30 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-10-13 | 2017-11-30 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-13 | 2017-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-10-13 | 2017-11-30 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-13 | 2017-11-30 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-10-13 | 2017-11-30 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-13 | 2017-11-30 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-13 | 2017-11-30 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-10-13 | 2017-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-08 | 2017-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-11-08 | 2017-11-30 | N |
