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Deficiency Records for Ormsby Post Acute Rehabilitation
View the most recent health deficiencies and inspection results for Ormsby Post Acute Rehabilitation. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Ormsby Post Acute Rehabilitation. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-03-26 | 2026-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2026-03-26 | 2026-04-30 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-03-27 | 2025-04-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2025-03-27 | 2025-04-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2025-03-27 | 2025-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-03-27 | 2025-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-27 | 2025-04-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-03-27 | 2025-04-14 | 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 | 2025-03-27 | 2025-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-27 | 2025-04-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-03-27 | 2025-04-14 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2025-03-27 | 2025-04-14 | Y |
| 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 | 2025-03-27 | 2025-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-03-27 | 2025-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-27 | 2025-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-27 | 2025-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-03-27 | 2025-04-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-03-27 | 2025-04-10 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-09-18 | 2024-11-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-18 | 2024-11-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-18 | 2024-11-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-18 | 2024-11-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-29 | 2024-07-24 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-05-29 | 2024-07-24 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-05-29 | 2024-07-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-29 | 2024-07-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-29 | 2024-07-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-29 | 2024-07-24 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide training in compliance and ethics. | Health | 2024-05-29 | 2024-07-24 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-05-29 | 2024-07-24 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-29 | 2024-07-24 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-05-29 | 2024-07-24 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-05-29 | 2024-07-24 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-29 | 2024-07-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-29 | 2024-07-24 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-05-29 | 2024-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-29 | 2024-07-24 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-05-29 | 2024-07-24 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2024-05-29 | 2024-07-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-29 | 2024-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-29 | 2024-07-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-29 | 2024-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-16 | 2024-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-16 | 2024-03-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-16 | 2024-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-16 | 2024-03-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-16 | 2024-03-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-16 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-05 | 2023-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-05 | 2023-08-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-05 | 2023-08-15 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-07-05 | 2023-08-15 | 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 (including nights and weekends) and emergencies. | Health | 2023-07-05 | 2023-08-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-05 | 2023-08-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-05 | 2023-08-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-05 | 2023-08-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-07-05 | 2023-08-15 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-07-05 | 2023-08-15 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-07-05 | 2023-08-15 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-07-05 | 2023-08-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-07-05 | 2023-08-15 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-05 | 2023-08-15 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-07-05 | 2023-08-15 | N |
| Provide training in compliance and ethics. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-05 | 2023-08-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-05 | 2023-07-29 | 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 | 2023-07-05 | 2023-07-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Develop a communication plan. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Establish methods for sharing information. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-05 | 2023-07-29 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-05 | 2023-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-05 | 2023-07-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-05 | 2023-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-05 | 2023-07-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-05 | 2023-07-29 | 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 | 2023-07-05 | 2023-07-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-07-05 | 2023-07-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-05 | 2023-07-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-05 | 2023-07-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-05 | 2023-07-29 | N |