Deficiency Records for Our Ladys Center For Rehabilitation and Healthcare
Updated as of March 01, 2024
A list of the most recent deficiencies for Our Ladys 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? |
|---|---|---|---|---|
| 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 | 2023-11-22 | 2024-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-22 | 2024-01-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-22 | 2024-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-22 | 2024-01-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-11-22 | 2024-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-22 | 2024-01-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-22 | 2024-01-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-22 | 2024-01-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-22 | 2024-01-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-22 | 2024-01-12 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-06-01 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-05-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-09 | 2022-02-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-09 | 2022-02-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-02-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-09 | 2022-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-09 | 2022-02-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-09 | 2022-02-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-09 | 2022-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-23 | 2022-02-08 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-11-23 | 2021-12-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-10 | 2020-01-09 | N |
