Deficiency Records for Betsy Ross Rehabilitation Center, Inc
Updated as of March 01, 2024
A list of the most recent deficiencies for Betsy Ross 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-01 | 2024-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-01 | 2024-02-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-01 | 2024-02-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-01 | 2024-02-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-01 | 2024-02-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-01 | 2024-01-29 | 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 | 2023-12-01 | 2024-01-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-12-01 | 2024-01-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-12-01 | 2024-01-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-01 | 2024-01-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-01 | 2024-01-29 | 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 | 2023-12-01 | 2024-01-25 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-12-01 | 2024-01-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-01 | 2024-01-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2024-01-25 | 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 | 2023-12-01 | 2024-01-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2024-01-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-06-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-02 | 2023-05-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2023-01-31 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-25 | 2022-06-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-08 | 2021-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-08 | 2021-12-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-08 | 2021-12-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-08 | 2021-12-02 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-08 | 2021-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-08 | 2021-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-12-02 | Y |
| 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 | 2021-10-08 | 2021-12-02 | 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 | 2021-10-08 | 2021-12-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-10-08 | 2021-12-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-10-08 | 2021-11-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-21 | 2021-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-21 | 2021-07-12 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-05-21 | 2021-07-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-01 | 2021-05-01 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-26 | 2019-05-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-03-26 | 2019-05-25 | 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 | 2019-03-26 | 2019-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-26 | 2019-05-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-03-22 | 2019-05-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-22 | 2019-05-21 | N |
