Deficiency Records for Livingston Hills Nursing and Rehabilitation Center
Updated as of August 01, 2024
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Deficiency Records for Livingston Hills Nursing and Rehabilitation Center
A list of the most recent deficiencies for Livingston Hills Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Livingston Hills Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| 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 | 2023-05-10 | 2023-08-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-10 | 2023-08-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-12 | 2023-08-04 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-05-10 | 2023-07-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-10 | 2023-07-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-10 | 2023-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-10 | 2023-07-07 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-05-10 | 2023-07-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-10 | 2023-07-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-12 | 2023-07-07 | 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 | 2023-05-12 | 2023-07-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-12 | 2023-07-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-20 | 2022-11-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-20 | 2022-11-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-20 | 2022-11-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-20 | 2022-11-04 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-09-20 | 2022-11-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-20 | 2022-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-20 | 2022-11-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-11 | 2022-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-30 | Y |
| 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 | 2021-04-14 | 2021-06-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-14 | 2021-06-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-14 | 2021-06-08 | 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 | 2021-04-14 | 2021-06-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-14 | 2021-06-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-14 | 2021-06-08 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-04-14 | 2021-06-08 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-04-14 | 2021-06-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-14 | 2021-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-14 | 2021-05-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-23 | Not Fixed | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-23 | Not Fixed | 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 | 2024-05-23 | Not Fixed | 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 | 2024-05-23 | Not Fixed | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-05-23 | Not Fixed | N |
| Assess the resident when there is a significant change in condition | Health | 2024-05-23 | Not Fixed | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-23 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-23 | Not Fixed | 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 | 2024-05-23 | Not Fixed | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-23 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-23 | Not Fixed | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-05-23 | Not Fixed | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-23 | Not Fixed | 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 | 2024-05-23 | Not Fixed | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-23 | Not Fixed | 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 | 2024-05-23 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-23 | Not Fixed | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-23 | Not Fixed | 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 | 2024-05-23 | Not Fixed | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-23 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-23 | Not Fixed | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-24 | Not Fixed | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-24 | Not Fixed | 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 | 2024-05-24 | Not Fixed | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Install proper backup exit lighting. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-24 | Not Fixed | 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 | 2024-05-24 | Not Fixed | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-24 | Not Fixed | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2024-05-24 | Not Fixed | N |
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