Deficiency Records for Pelham Parkway Nursing Care and Rehab Facility L L C
Updated as of March 01, 2024
A list of the most recent deficiencies for Pelham Parkway Nursing Care and Rehab Facility L L C. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-06-23 | 2023-08-22 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-06-21 | 2023-08-18 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-06-21 | 2023-08-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-21 | 2023-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-21 | 2023-08-18 | 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 | 2023-06-21 | 2023-08-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-21 | 2023-08-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-21 | 2023-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-21 | 2023-08-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-23 | 2023-08-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-23 | 2023-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-23 | 2023-08-16 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-06-23 | 2023-08-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-01 | 2022-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-31 | 2022-03-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-27 | 2021-07-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-27 | 2021-07-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-27 | 2021-07-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-27 | 2021-07-16 | Y |
| 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 | 2021-04-13 | 2021-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-13 | 2021-06-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-04-13 | 2021-05-28 | Y |
| 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 | 2021-04-13 | 2021-05-28 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-04-13 | 2021-05-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-04-13 | 2021-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-13 | 2021-05-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-13 | 2021-05-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-13 | 2021-05-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-11 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-04-13 | 2021-04-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-07-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-27 | 2020-07-03 | 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 | 2020-02-27 | 2020-07-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-07-02 | 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 | 2020-02-27 | 2020-07-02 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2020-02-27 | 2020-07-01 | 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 | 2020-02-27 | 2020-07-01 | N |
