Deficiency Records for Rest Haven Convalescent and Retirement Home
Updated as of March 01, 2024
A list of the most recent deficiencies for Rest Haven Convalescent and Retirement Home. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-07-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-09 | 2023-01-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-09 | 2023-01-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-09 | 2023-01-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-09 | 2023-01-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Meet other general requirements. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-28 | 2020-03-12 | 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 | 2020-01-28 | 2020-03-12 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-28 | 2020-03-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-28 | 2020-03-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-01-28 | 2020-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-28 | 2020-03-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-28 | 2020-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-10 | 2019-02-23 | 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 | 2019-01-10 | 2019-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-02-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-01-10 | 2019-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-10 | 2019-02-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-01-10 | 2019-02-22 | N |
| Meet other general requirements. | Fire Safety | 2019-01-10 | 2019-02-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-10 | 2019-02-15 | 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 | 2019-01-10 | 2019-02-15 | N |
| Post nurse staffing information every day. | Health | 2019-01-10 | 2019-02-15 | 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 | 2019-01-10 | 2019-02-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-10 | 2019-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-10 | 2019-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-10 | 2019-01-14 | N |
