A list of the most recent deficiencies for East Carolina Rehab and Wellness. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-16 | 2024-03-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-27 | 2024-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-27 | 2024-03-26 | 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 | 2024-02-27 | 2024-03-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-27 | 2024-03-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-27 | 2024-03-26 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-27 | 2024-03-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-27 | 2024-03-26 | Y |
| 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 | 2023-11-02 | 2023-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-02 | 2023-11-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-02 | 2023-11-30 | 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 | 2023-11-02 | 2023-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-02 | 2023-11-30 | 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 | 2023-11-02 | 2023-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-02 | 2023-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-02 | 2023-11-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-01 | 2023-08-25 | Y |
| Meet other general requirements. | Fire Safety | 2022-07-28 | 2022-10-11 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-28 | 2022-10-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-28 | 2022-10-11 | 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 | 2022-07-28 | 2022-10-11 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-07-28 | 2022-10-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-28 | 2022-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-28 | 2022-10-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-30 | 2022-08-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-30 | 2022-08-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-06-30 | 2022-08-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-30 | 2022-08-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-30 | 2022-08-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-08-05 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-06-30 | 2022-08-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-30 | 2022-08-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-30 | 2022-08-05 | 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 | 2022-06-30 | 2022-08-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-30 | 2022-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-08-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-08-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-07-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-13 | 2021-07-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-13 | 2021-07-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-13 | 2021-06-03 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-04-13 | 2021-06-03 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-04-13 | 2021-06-03 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-04-13 | 2021-06-03 | Y |
| 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 | 2021-04-13 | 2021-06-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-13 | 2021-06-03 | Y |
| 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 | 2021-04-13 | 2021-06-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-13 | 2021-06-03 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-04-13 | 2021-06-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-13 | 2021-06-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-13 | 2021-06-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-13 | 2021-06-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-13 | 2021-06-03 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-04-13 | 2021-06-03 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-04-13 | 2021-06-03 | Y |
| 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 | 2021-04-13 | 2021-06-03 | Y |
| 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 | 2021-04-13 | 2021-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-06-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-13 | 2021-06-03 | Y |
