Deficiency Records for The Grand Rehabilitation and Nursing at Delaware Par
Updated as of April 01, 2024
A list of the most recent deficiencies for The Grand Rehabilitation and Nursing at Delaware Par. 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? |
|---|---|---|---|---|
| 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 | 2023-03-24 | 2023-05-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-24 | 2023-05-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-24 | 2023-05-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-24 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-24 | 2023-05-12 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-24 | 2023-05-12 | 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 | 2023-03-24 | 2023-05-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-24 | 2023-05-12 | 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 | 2023-03-24 | 2023-05-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-24 | 2023-05-12 | N |
| Keep all essential equipment working safely. | Health | 2023-01-03 | 2023-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-11 | 2022-07-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-12 | 2022-05-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-14 | 2021-06-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-14 | 2021-06-08 | 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 | 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-14 | 2021-06-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Have elevators that firefighters can control in the event of a fire. | 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 |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-14 | 2021-06-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-12 | 2019-09-21 | 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 | 2019-06-12 | 2019-08-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-12 | 2019-08-11 | 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 | 2019-06-12 | 2019-08-11 | 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 | 2019-06-12 | 2019-08-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-06-12 | 2019-08-11 | N |
| Use approved construction type or materials. | Fire Safety | 2021-04-14 | Not Fixed | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-12 | Not Fixed | N |
