Deficiency Records for Mattapan Health and Rehabilitation Center
Updated as of May 01, 2024
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Deficiency Records for Mattapan Health and Rehabilitation Center
A list of the most recent deficiencies for Mattapan Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mattapan 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-08 | 2024-04-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-08 | 2024-04-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-08 | 2024-04-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-08 | 2024-04-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-08 | 2024-04-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-08 | 2024-04-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-08 | 2024-04-15 | 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 | 2024-03-08 | 2024-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-08 | 2024-04-15 | 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 | 2024-03-08 | 2024-04-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-08 | 2024-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-08 | 2024-04-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-08 | 2024-04-15 | N |
| Provide appropriate foot care. | Health | 2024-03-08 | 2024-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-08 | 2024-04-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-08 | 2024-04-15 | 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 | 2024-03-08 | 2024-04-15 | N |
| Post nurse staffing information every day. | Health | 2024-03-08 | 2024-04-15 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-03-08 | 2024-04-15 | 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 | 2024-03-08 | 2024-04-15 | 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 | 2024-03-08 | 2024-04-15 | 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 | 2024-03-08 | 2024-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-08 | 2024-04-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-03-08 | 2024-04-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-08 | 2024-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-08 | 2024-04-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-08 | 2024-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-18 | 2024-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-18 | 2024-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-18 | 2024-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-09-25 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-25 | 2023-03-31 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-01-25 | 2023-03-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-01-25 | 2023-03-31 | 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 | 2023-01-25 | 2023-03-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-25 | 2023-03-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-25 | 2023-03-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-20 | 2023-03-05 | 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 | 2023-01-20 | 2023-03-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-20 | 2023-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-03-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-20 | 2023-03-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-20 | 2023-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-20 | 2023-03-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-20 | 2023-03-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-03-05 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-01-20 | 2023-03-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-20 | 2023-03-05 | 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 | 2023-01-20 | 2023-03-05 | 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 | 2023-01-20 | 2023-03-05 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-20 | 2023-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-20 | 2023-03-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-20 | 2023-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-20 | 2023-03-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-25 | 2023-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-03 | 2022-04-07 | 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 | 2022-02-03 | 2022-04-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-03 | 2022-04-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-03 | 2022-04-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-03 | 2022-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-03 | 2022-04-07 | 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 | 2022-02-03 | 2022-04-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-23 | 2022-03-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-23 | 2022-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-23 | 2022-03-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-03 | 2022-03-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-03 | 2022-03-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-03-14 | N |
| Respond appropriately to all alleged violations. | Health | 2022-02-03 | 2022-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-14 | 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 | 2022-02-03 | 2022-03-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-02-03 | 2022-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-03-14 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-02-03 | 2022-03-14 | 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 | 2022-02-03 | 2022-03-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-02-03 | 2022-03-14 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-03 | 2022-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-03 | 2022-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-14 | N |
| Keep all essential equipment working safely. | Health | 2022-02-03 | 2022-03-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-03 | 2022-03-14 | N |
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