Deficiency Records for Douglas Cove Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Douglas Cove 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? |
|---|---|---|---|---|
| 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 | 2023-06-07 | 2023-07-14 | 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 | 2023-06-07 | 2023-07-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-07-14 | 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 | 2023-06-07 | 2023-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-07 | 2023-07-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-07 | 2023-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2022-12-22 | 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 | 2022-03-10 | 2022-05-13 | 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 | 2022-03-10 | 2022-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-04-14 | 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 | 2022-03-10 | 2022-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-10 | 2022-04-12 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-03-10 | 2022-04-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-10 | 2022-04-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-10 | 2022-04-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-10 | 2022-04-12 | 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 | 2022-03-10 | 2022-04-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-10 | 2022-04-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-10 | 2022-04-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-10 | 2022-04-12 | 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 | 2022-03-10 | 2022-04-12 | 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 | 2022-03-10 | 2022-04-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-10 | 2022-04-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-10 | 2022-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-10 | 2022-04-12 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-10 | 2022-04-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-10 | 2022-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-13 | 2020-03-13 | 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 | 2020-02-12 | 2020-03-06 | 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 | 2020-02-12 | 2020-03-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-12 | 2020-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-12 | 2020-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-12 | 2020-03-06 | N |
