A list of the most recent deficiencies for Englewood Health and Rehab. 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? |
|---|---|---|---|---|
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-29 | 2024-02-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-11 | 2023-10-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-11 | 2023-10-06 | 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 | 2023-09-11 | 2023-10-06 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-09-11 | 2023-10-06 | Y |
| 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 | 2023-06-15 | 2023-07-20 | N |
| 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 | 2023-06-15 | 2023-07-20 | 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 | 2023-06-15 | 2023-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-15 | 2023-07-20 | 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 | 2023-06-13 | 2023-07-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-13 | 2023-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-17 | 2023-02-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-02 | 2022-09-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-17 | 2022-09-03 | 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 | 2022-08-17 | 2022-09-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-03 | 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 | 2022-08-17 | 2022-09-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-21 | 2022-09-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-21 | 2022-09-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-21 | 2022-09-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-21 | 2022-09-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-21 | 2022-07-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-28 | 2022-01-18 | 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 | 2020-01-16 | 2020-02-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-16 | 2020-02-27 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2020-01-16 | 2020-02-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-16 | 2020-02-27 | 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 | 2020-01-16 | 2020-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-16 | 2020-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-16 | 2020-02-27 | 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 | 2020-01-16 | 2020-02-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-16 | 2020-02-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-01-16 | 2020-02-27 | 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 | 2020-01-16 | 2020-02-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-16 | 2020-02-27 | 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 | 2020-01-16 | 2020-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-16 | 2020-02-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-15 | 2020-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-15 | 2020-02-27 | 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 | 2018-10-29 | 2019-04-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-02 | 2018-12-02 | 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 | 2018-11-02 | 2018-12-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-02 | 2018-12-02 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-11-02 | 2018-12-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-02 | 2018-12-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-02 | 2018-12-02 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-02 | 2018-12-02 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-11-02 | 2018-12-02 | 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 | 2018-11-02 | 2018-12-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-02 | 2018-12-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-02 | 2018-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-02 | 2018-12-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-02 | 2018-12-02 | 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 | 2018-11-02 | 2018-12-02 | 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 | 2018-11-02 | 2018-12-02 | 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 | 2018-11-02 | 2018-12-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-02 | 2018-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-02 | 2018-12-02 | 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 | 2018-10-29 | 2018-12-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-29 | 2018-12-02 | N |
