Deficiency Records for Tolstoy Foundation Rehabilitation and Nrsg Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Tolstoy Foundation Rehabilitation and Nrsg 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? |
|---|---|---|---|---|
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2021-06-15 | 2021-09-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-15 | 2021-09-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-15 | 2021-09-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-15 | 2021-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-15 | 2021-09-08 | 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 | 2021-06-15 | 2021-09-08 | 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 | 2021-06-15 | 2021-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-15 | 2021-09-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-15 | 2021-09-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-06-15 | 2021-08-10 | 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 | 2021-06-15 | 2021-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-15 | 2021-08-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-04 | 2020-01-17 | 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 | 2019-12-04 | 2020-01-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-04 | 2020-01-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-04 | 2020-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-04 | 2020-01-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-04 | 2020-01-17 | N |
| Post nurse staffing information every day. | Health | 2019-12-04 | 2020-01-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-04 | 2020-01-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-04 | 2020-01-17 | 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 | 2019-12-04 | 2020-01-17 | 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 | 2019-12-04 | 2020-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-04 | 2020-01-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-04 | 2020-01-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-03-30 | 2018-06-22 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Develop a communication plan. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-03-30 | 2018-06-11 | 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 | 2018-03-30 | 2018-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-30 | 2018-06-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-03-27 | 2018-05-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-03-27 | 2018-05-24 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-03-27 | 2018-05-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-27 | 2018-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-27 | 2018-05-24 | N |
| Provide activities to meet all resident's needs. | Health | 2018-03-27 | 2018-05-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-27 | 2018-05-24 | 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 | 2018-03-27 | 2018-05-24 | N |
