Deficiency Records for Roaring River Health and Rehabilitation
Updated as of May 01, 2024
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Deficiency Records for Roaring River Health and Rehabilitation
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.
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-01 | 2024-04-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-01 | 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 | 2024-03-01 | 2024-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-01 | 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 | 2024-03-01 | 2024-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-01 | 2024-04-15 | 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 | 2024-03-01 | 2024-04-15 | 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 | 2024-03-01 | 2024-04-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-03-01 | 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 | 2024-03-01 | 2024-04-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-01 | 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 | 2024-03-01 | 2024-04-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-01 | 2024-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-01 | 2024-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-01 | 2024-04-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-01 | 2024-04-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-03-01 | 2024-04-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-01 | 2024-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-01 | 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 | 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 |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-12-14 | Not Fixed | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-01 | Not Fixed | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-01 | Not Fixed | N |
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