Deficiency Records for Sinai Post Acute Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Sinai Post Acute Nursing and Rehab Center. 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? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-12-22 | 2024-02-20 | 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 | 2023-12-22 | 2024-02-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-22 | 2024-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-22 | 2024-02-20 | 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 | 2023-12-22 | 2024-02-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-22 | 2024-02-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-22 | 2024-01-16 | 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 | 2023-12-22 | 2024-01-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-22 | 2024-01-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-22 | 2024-01-16 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-12-22 | 2024-01-16 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-12-22 | 2024-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-22 | 2024-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-22 | 2024-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-12-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-18 | 2021-09-20 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-09-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-18 | 2021-08-27 | 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 | 2021-08-18 | 2021-08-27 | 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 | 2021-08-18 | 2021-08-27 | 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 | 2021-08-18 | 2021-08-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-08-18 | 2021-08-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-18 | 2021-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-18 | 2021-08-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-08-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-18 | 2021-08-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-18 | 2021-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-18 | 2021-08-26 | 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 | 2021-08-18 | 2021-08-26 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-08-18 | 2021-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-21 | 2021-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-27 | 2019-10-25 | 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 | 2019-08-27 | 2019-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-27 | 2019-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-27 | 2019-10-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-27 | 2019-10-25 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-08-27 | 2019-10-25 | 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 | 2019-08-27 | 2019-10-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-27 | 2019-10-25 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-27 | 2019-10-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-27 | 2019-10-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-27 | 2019-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-27 | 2019-10-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-27 | 2019-10-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-27 | 2019-10-25 | N |
