Deficiency Records for Campbell Hall Rehabilitation Center Inc
Updated as of March 01, 2024
A list of the most recent deficiencies for Campbell Hall Rehabilitation Center Inc. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | 2023-08-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-23 | 2023-06-01 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-20 | 2022-09-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-20 | 2022-08-08 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-20 | 2022-06-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-29 | 2022-06-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-29 | 2022-06-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-29 | 2022-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-29 | 2022-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-29 | 2022-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-29 | 2022-06-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-29 | 2022-06-21 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-29 | 2022-06-21 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Meet other general requirements. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Have an externally vented heating system. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-20 | 2022-06-18 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-22 | 2022-01-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-22 | 2022-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2022-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-22 | 2022-01-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-20 | 2021-12-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-24 | 2021-08-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-24 | 2021-08-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-24 | 2021-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-24 | 2021-08-13 | 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 | 2021-06-24 | 2021-08-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-24 | 2021-08-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-08-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-24 | 2021-08-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-24 | 2021-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-08-13 | 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 | 2021-06-24 | 2021-08-13 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-06-24 | 2021-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-08-13 | 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 | 2021-06-24 | 2021-08-13 | Y |
| Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-19 | 2021-06-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-19 | 2021-06-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-19 | 2021-06-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-18 | 2021-04-23 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-05 | 2019-05-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-05 | 2019-05-31 | 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 | 2019-04-05 | 2019-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-05 | 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 | 2019-04-05 | 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 | 2019-04-05 | 2019-05-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-04-05 | 2019-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-05 | 2019-05-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-05 | 2019-05-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-04-05 | 2019-05-24 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-05 | 2019-05-24 | 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 | 2019-04-05 | 2019-05-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-05 | 2019-05-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-05 | 2019-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-24 | N |
