Deficiency Records for Hertford Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Hertford Rehabilitation and Healthcare Center. 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-31 | 2023-06-19 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-28 | 2023-03-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-31 | 2023-02-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-31 | 2023-02-22 | 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 | 2023-01-31 | 2023-02-22 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-31 | 2023-02-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-31 | 2023-02-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-01-31 | 2023-02-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-31 | 2023-02-22 | N |
| Post nurse staffing information every day. | Health | 2023-01-31 | 2023-02-22 | 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 | 2023-01-31 | 2023-02-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-31 | 2023-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-31 | 2023-02-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-31 | 2023-02-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-31 | 2023-02-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-01-31 | 2023-02-22 | 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 | 2023-01-31 | 2023-02-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-31 | 2023-02-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-31 | 2023-02-22 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-31 | 2023-02-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-31 | 2023-02-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-31 | 2023-02-22 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-31 | 2023-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-08 | 2022-07-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-25 | 2022-05-13 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-24 | 2022-05-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-24 | 2022-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-24 | 2022-04-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-24 | 2022-04-25 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-26 | 2021-11-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-10-26 | 2021-11-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-26 | 2021-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-26 | 2021-11-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-26 | 2021-11-17 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-04-15 | 2021-04-16 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-18 | 2019-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-18 | 2019-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-18 | 2019-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-18 | 2019-08-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-13 | 2019-07-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-13 | 2019-07-01 | 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 | 2019-06-13 | 2019-06-27 | N |
