Deficiency Records for Derry Center For Rehabilitation and Healthcare
Updated as of March 01, 2024
A list of the most recent deficiencies for Derry Center For Rehabilitation and Healthcare. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-10 | 2023-11-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-10 | 2023-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-10 | 2023-11-08 | 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 | 2023-10-12 | 2023-10-27 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-27 | 2023-04-11 | Y |
| 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 | 2023-03-27 | 2023-04-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-27 | 2023-03-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-27 | 2023-03-29 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-27 | 2023-03-29 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-05 | 2022-10-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-10-05 | 2022-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-05 | 2022-10-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-05 | 2022-10-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-05 | 2022-10-21 | N |
| 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 | 2022-10-04 | 2022-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-04 | 2022-10-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-01 | 2021-12-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-11-01 | 2021-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-01 | 2021-12-31 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-01 | 2021-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-01 | 2021-12-31 | N |
| Provide activities to meet all resident's needs. | Health | 2021-11-01 | 2021-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-01 | 2021-12-31 | 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 | 2021-11-01 | 2021-12-31 | 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 | 2021-11-01 | 2021-12-31 | 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 | 2021-11-01 | 2021-12-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-01 | 2021-12-31 | 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 | 2021-11-01 | 2021-12-31 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-11-01 | 2021-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-01 | 2021-12-31 | N |
| Report COVID19 data to residents and families. | Health | 2021-11-01 | 2021-12-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-01 | 2021-12-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-04 | 2021-12-29 | 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 | 2021-11-04 | 2021-12-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-04 | 2021-12-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-04 | 2021-12-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-04 | 2021-12-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-04 | 2021-12-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-04 | 2021-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-06-29 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-03-19 | 2021-04-10 | Y |
