A list of the most recent deficiencies for Pruitthealth-Rockingham. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-13 | 2024-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-13 | 2024-01-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-13 | 2024-01-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-16 | 2023-12-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-16 | 2023-12-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-16 | 2023-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2023-12-14 | 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 | 2023-11-16 | 2023-12-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-16 | 2023-12-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-16 | 2023-12-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-16 | 2023-12-14 | 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 | 2023-11-16 | 2023-12-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-16 | 2023-12-14 | 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 | 2023-11-16 | 2023-12-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-16 | 2023-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-24 | 2023-06-15 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-10-04 | 2022-12-02 | 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 | 2022-10-04 | 2022-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-04 | 2022-12-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-04 | 2022-12-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-04 | 2022-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-04 | 2022-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-12-02 | 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 | 2022-08-31 | 2022-09-20 | 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 | 2022-08-31 | 2022-09-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-31 | 2022-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-31 | 2022-09-20 | 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 | 2022-08-31 | 2022-09-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-31 | 2022-09-20 | N |
| Post nurse staffing information every day. | Health | 2022-08-31 | 2022-09-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-31 | 2022-09-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-31 | 2022-09-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-31 | 2022-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-31 | 2022-09-20 | 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 | 2022-08-31 | 2022-09-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-18 | 2022-04-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-18 | 2022-03-18 | Y |
| 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 | 2022-02-18 | 2022-03-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-03-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-18 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-06-04 | 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 | 2021-04-28 | 2021-05-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-28 | 2021-05-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-26 | 2021-05-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-03-26 | 2021-05-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-26 | 2021-05-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-03-26 | 2021-05-19 | 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 | 2021-03-26 | 2021-05-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-26 | 2021-05-19 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-26 | 2021-05-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-03-26 | 2021-05-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-26 | 2021-05-19 | N |
| 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 | 2021-03-26 | 2021-05-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-03-26 | 2021-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-26 | 2021-05-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-26 | 2021-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-26 | 2021-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2021-05-19 | Y |
