Deficiency Records for North End Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for North End Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2023-07-13 | 2023-07-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-13 | 2023-07-16 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-04 | 2023-05-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-04 | 2023-05-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-04 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-05-15 | N |
| Have an externally vented heating system. | Fire Safety | 2023-04-04 | 2023-05-15 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2023-04-04 | 2023-05-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-24 | 2023-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-24 | 2023-04-14 | 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 | 2023-03-24 | 2023-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-24 | 2023-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-04-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-24 | 2023-04-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-24 | 2023-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-24 | 2023-04-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-24 | 2023-04-14 | 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 | 2023-03-24 | 2023-04-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-24 | 2023-04-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-24 | 2023-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-25 | 2022-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-25 | 2022-06-15 | N |
| Keep all essential equipment working safely. | Health | 2022-04-25 | 2022-06-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-25 | 2022-06-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-25 | 2022-06-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-25 | 2022-06-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-25 | 2022-06-08 | 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 | 2022-04-25 | 2022-06-08 | 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 | 2022-04-25 | 2022-06-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-25 | 2022-06-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-25 | 2022-06-08 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-04-25 | 2022-06-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-05 | 2022-06-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-05 | 2022-06-03 | 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 | 2022-05-05 | 2022-06-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-05 | 2022-06-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-05-05 | 2022-06-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-05 | 2022-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-01-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-27 | 2021-10-05 | Y |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-09-10 | 2019-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-10 | 2019-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-01 | 2019-07-26 | 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 | 2019-07-01 | 2019-07-26 | N |
