Deficiency Records for Roaring River Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Roaring River 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? |
|---|---|---|---|---|
| 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 | 2022-09-21 | 2022-11-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-21 | 2022-11-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-31 | 2022-09-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2022-02-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-10 | 2022-02-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-12-10 | 2022-02-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-10 | 2022-02-07 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-12-10 | 2022-01-24 | 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 | 2021-12-10 | 2022-01-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-10 | 2022-01-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-10 | 2022-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-10 | 2022-01-24 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-10 | 2022-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-10 | 2022-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-10 | 2022-01-24 | 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 | 2021-12-10 | 2022-01-24 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-10 | 2022-01-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-05 | 2019-07-25 | 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 | 2019-06-05 | 2019-07-18 | 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 | 2019-06-05 | 2019-07-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-05 | 2019-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-05 | 2019-07-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-05 | 2019-07-18 | 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 | 2019-06-05 | 2019-07-18 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-05 | 2019-07-18 | 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 | 2019-06-05 | 2019-07-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-22 | 2018-09-14 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-22 | 2018-09-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-22 | 2018-08-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-22 | 2018-08-06 | 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 | 2018-06-22 | 2018-08-06 | 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 | 2018-06-22 | 2018-08-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-06-22 | 2018-08-06 | 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 | 2018-06-22 | 2018-08-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-06-22 | 2018-08-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-22 | 2018-08-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-06-22 | 2018-08-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-12-14 | Not Fixed | Y |
