Deficiency Records for The Reservoir Center For Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for The Reservoir Center For Health and Rehabilitation. 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 safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-11 | 2023-08-02 | 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 | 2023-07-11 | 2023-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-11 | 2023-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-04 | 2023-01-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-04 | 2023-01-19 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-04 | 2023-01-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-04 | 2023-01-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-04 | 2021-12-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-04 | 2021-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-04 | 2021-12-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-04 | 2021-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-04 | 2021-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-26 | 2021-12-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-26 | 2021-12-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-26 | 2021-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-26 | 2021-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-26 | 2021-12-15 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-26 | 2021-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-26 | 2021-12-15 | 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 | 2021-10-26 | 2021-12-15 | 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 | 2021-10-26 | 2021-12-15 | 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 | 2021-10-26 | 2021-12-15 | 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 | 2021-10-26 | 2021-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-26 | 2021-12-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-26 | 2021-12-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-26 | 2021-12-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-26 | 2021-12-15 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-10-26 | 2021-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Have proper openings in smoke barrier doors. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-10 | 2019-08-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-26 | 2019-08-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-06-26 | 2019-08-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-26 | 2019-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-26 | 2019-08-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-26 | 2019-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-26 | 2019-08-08 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-06-26 | 2019-08-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-26 | 2019-08-08 | N |
