Deficiency Records for Campbell Hall Rehabilitation Center Inc
Updated as of January 01, 2022
This is not the most recent data for Campbell Hall Rehabilitation Center Inc. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Respond appropriately to all alleged violations. | Health | 2021-03-18 | 2021-04-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-08-13 | 2020-10-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-08-13 | 2020-10-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-08-13 | 2020-10-04 | Y |
| 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 | 2020-08-13 | 2020-10-04 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2020-08-13 | 2020-10-04 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-08-13 | 2020-10-04 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-08-13 | 2020-10-04 | Y |
| Develop a communication plan. | Fire Safety | 2020-08-13 | 2020-10-04 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2020-08-13 | 2020-10-04 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-07-09 | 2019-08-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-07-09 | 2019-08-15 | 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-07-17 | 2017-08-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-07-17 | 2017-08-25 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-17 | 2017-08-25 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-07-17 | 2017-08-25 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-07-17 | 2017-08-25 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-17 | 2017-08-25 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-07-17 | 2017-08-25 | 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 | 2017-07-17 | 2017-08-25 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2017-07-17 | 2017-08-25 | N |
| Operate and provide services according to Federal, State, and local laws and professional standards. | Health | 2017-07-17 | 2017-08-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-07-17 | 2017-08-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-07-17 | 2017-08-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-07-17 | 2017-08-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-07-17 | 2017-08-25 | N |
