A list of the most recent deficiencies for Achieve Rehab and Nursing Facility. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-27 | 2022-11-25 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-09-27 | 2022-11-25 | 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 | 2022-09-27 | 2022-11-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-09-27 | 2022-11-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-27 | 2022-11-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-27 | 2022-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-27 | 2022-11-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-27 | 2022-11-25 | 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 | 2022-09-27 | 2022-10-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-10-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-27 | 2022-10-24 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-09-27 | 2022-10-24 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-27 | 2022-10-24 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-28 | 2019-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-28 | 2019-05-24 | 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 | 2019-03-28 | 2019-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-28 | 2019-05-24 | 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 | 2019-03-28 | 2019-05-24 | 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 | 2019-03-28 | 2019-05-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-03-28 | 2019-05-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-03-28 | 2019-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-28 | 2019-05-23 | N |
| Give notice to the resident before a room or roommate change. | Health | 2017-06-05 | 2017-07-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-05 | 2017-07-25 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-06-05 | 2017-07-25 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-06-05 | 2017-07-25 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-05 | 2017-07-25 | 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 | 2017-06-05 | 2017-07-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-06-05 | 2017-07-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-05 | 2017-07-25 | N |
