Deficiency Records for Gallup Nursing and Rehabilitation LLC
Updated as of October 01, 2021
This is not the most recent data for Gallup Nursing and Rehabilitation LLC. For the most recent information, click here.
A list of the most recent deficiencies for Gallup Nursing and Rehabilitation LLC. 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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-03 | 2021-04-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-03 | 2021-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-03 | 2021-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-03 | 2021-04-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-03-04 | 2021-04-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-03-04 | 2021-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-04 | 2021-04-15 | 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 | 2021-03-04 | 2021-04-15 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-03-04 | 2021-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-04 | 2021-04-15 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-04 | 2021-04-15 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-03-04 | 2021-04-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-12 | 2020-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-12 | 2020-08-10 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-03-12 | 2020-08-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-15 | 2020-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-10 | 2019-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-10 | 2019-08-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-12 | 2019-08-19 | 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 | 2019-07-12 | 2019-08-19 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-07-12 | 2019-08-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-12 | 2019-08-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-12 | 2019-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-12 | 2019-08-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-12 | 2019-08-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-20 | 2018-10-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-20 | 2018-10-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-20 | 2018-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-20 | 2018-10-20 | 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 | 2018-09-20 | 2018-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-20 | 2018-10-20 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-09-20 | 2018-10-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-09-20 | 2018-10-20 | 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 | 2018-09-20 | 2018-10-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-20 | 2018-10-20 | 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 | 2018-09-20 | 2018-10-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-20 | 2018-10-20 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-20 | 2018-10-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-20 | 2018-10-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-20 | 2018-10-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-25 | 2018-10-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-25 | 2018-10-09 | N |
