A list of the most recent deficiencies for Treyburn Rehabilitation 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-11 | 2023-09-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-11 | 2023-09-01 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-04-27 | 2023-06-23 | 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 | 2023-04-27 | 2023-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-06-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-30 | 2023-04-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-30 | 2023-04-27 | 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 | 2023-03-30 | 2023-04-27 | 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 | 2023-03-30 | 2023-04-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-03-30 | 2023-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-30 | 2023-04-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-30 | 2023-04-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-30 | 2023-04-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-30 | 2023-04-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-30 | 2023-04-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-30 | 2023-04-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-30 | 2023-04-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-30 | 2023-04-27 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-30 | 2022-04-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-30 | 2022-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-30 | 2022-04-21 | N |
| Provide appropriate foot care. | Health | 2022-03-03 | 2022-03-31 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-03 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-03-31 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-11-10 | 2021-11-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-04 | 2020-03-25 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-03-04 | 2020-03-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-03-04 | 2020-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-04 | 2020-03-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-14 | 2020-03-13 | 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 | 2020-02-14 | 2020-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-14 | 2020-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-14 | 2020-03-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-14 | 2020-03-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-14 | 2020-03-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-14 | 2020-03-13 | 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 | 2020-02-14 | 2020-03-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-02-14 | 2020-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-14 | 2020-03-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-14 | 2020-03-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-14 | 2020-03-13 | N |
