Deficiency Records for Hospitality Center For Rehabilitation and Healing
Updated as of March 01, 2024
A list of the most recent deficiencies for Hospitality Center For Rehabilitation and Healing. 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? |
|---|---|---|---|---|
| Provide appropriate foot care. | Health | 2024-01-03 | 2024-01-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | 2024-01-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-03 | 2024-01-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-03 | 2023-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-17 | 2023-11-03 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-10-05 | 2023-11-03 | 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 | 2023-10-05 | 2023-11-03 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-05 | 2023-11-03 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-05 | 2023-11-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-05 | 2023-11-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-05 | 2023-11-03 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-28 | 2023-11-03 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-28 | 2023-11-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-28 | 2023-11-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-28 | 2023-11-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-22 | 2023-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-27 | 2023-05-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-27 | 2023-05-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-10 | 2023-03-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-10 | 2023-03-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-10 | 2023-03-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-01 | 2023-01-10 | 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 | 2022-12-01 | 2023-01-10 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-12-01 | 2023-01-10 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-12-01 | 2023-01-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-01 | 2023-01-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2023-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2023-01-10 | 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 | 2022-10-14 | 2022-11-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-22 | 2022-11-15 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-06-30 | 2022-09-08 | 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 | 2022-06-30 | 2022-09-08 | 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 | 2022-09-08 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-06-30 | 2022-09-08 | N |
| Provide or obtain dental services for each resident. | Health | 2022-06-30 | 2022-09-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-30 | 2022-09-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-30 | 2022-09-08 | 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 | 2022-09-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-30 | 2022-09-08 | 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 | 2022-08-10 | 2022-09-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-10 | 2022-09-08 | 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 | 2022-06-30 | 2022-09-08 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-06-30 | 2022-09-08 | 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 | 2022-06-30 | 2022-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-30 | 2022-09-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-15 | 2022-06-06 | 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 | 2022-05-15 | 2022-06-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-15 | 2022-06-06 | 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 | 2022-05-15 | 2022-06-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-15 | 2022-06-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-25 | 2022-06-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-25 | 2022-06-06 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-25 | 2022-06-06 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-25 | 2022-06-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-25 | 2022-06-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-01 | 2022-06-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-01 | 2022-06-06 | Y |
| Provide immediate access to any resident. | Health | 2021-11-19 | 2021-12-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-12 | 2021-09-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-12 | 2021-09-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-02 | 2021-09-10 | 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 | 2021-04-08 | 2021-05-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-08 | 2021-05-13 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-08 | 2021-05-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-08 | 2021-05-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-15 | 2020-03-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-01-15 | 2020-03-03 | 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 | 2020-01-15 | 2020-03-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-15 | 2020-03-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-01-15 | 2020-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-15 | 2020-03-03 | 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 | 2020-01-15 | 2020-03-03 | 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 | 2020-01-15 | 2020-03-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-15 | 2020-03-03 | 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 | 2020-01-15 | 2020-03-03 | 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 | 2020-01-15 | 2020-03-03 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-15 | 2020-03-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-15 | 2020-03-03 | N |
| 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 | 2020-01-15 | 2020-03-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-15 | 2020-03-03 | 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 | 2020-01-15 | 2020-03-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-15 | 2020-03-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-15 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-29 | 2019-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-29 | 2019-04-01 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2018-11-29 | 2019-04-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-29 | 2019-03-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-29 | 2019-03-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-11-29 | 2019-03-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-29 | 2019-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-29 | 2019-03-20 | 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 | 2018-11-29 | 2019-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-29 | 2019-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2019-03-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-29 | 2019-03-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-11-29 | 2019-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-29 | 2019-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-03-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-29 | 2019-03-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-11-29 | 2018-12-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-29 | 2018-12-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-29 | 2018-12-28 | N |
