Deficiency Records for Hall of Fame Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Hall of Fame Rehabilitation and Nursing 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? |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-28 | 2024-03-29 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-03-29 | Y |
Keep all essential equipment working safely. | Health | 2024-02-28 | 2024-03-29 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-28 | 2024-03-29 | 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 | 2023-08-11 | 2023-08-25 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-21 | 2023-08-04 | 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 | 2023-05-01 | 2023-06-16 | 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 | 2023-05-01 | 2023-06-05 | N |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-01 | 2023-06-05 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-01 | 2023-06-05 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-01 | 2023-06-05 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-01 | 2023-06-05 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-01 | 2023-06-05 | N |
Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-05-01 | 2023-06-05 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-01 | 2023-06-05 | N |
Dispose of garbage and refuse properly. | Health | 2023-05-01 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | N |
Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-17 | 2022-07-15 | 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 | 2022-06-17 | 2022-07-15 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-17 | 2022-07-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-07-15 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-17 | 2021-12-14 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-17 | 2021-12-14 | Y |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-17 | 2021-12-14 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-17 | 2021-12-14 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-10-29 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-06-30 | 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 | 2021-05-13 | 2021-06-30 | 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 | 2021-05-13 | 2021-06-30 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-13 | 2021-06-30 | 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 | 2021-05-18 | 2021-06-30 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-18 | 2021-06-11 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-18 | 2021-06-11 | N |
Develop a communication plan. | Fire Safety | 2021-05-18 | 2021-06-11 | N |
Establish emergency prep training and testing. | Fire Safety | 2021-05-18 | 2021-06-11 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-02 | 2020-02-05 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-02 | 2020-02-05 | 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 | 2020-01-02 | 2020-02-05 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-02 | 2020-02-05 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-02 | 2020-02-05 | N |
Respond appropriately to all alleged violations. | Health | 2020-01-02 | 2020-02-05 | 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 | 2020-01-02 | 2020-02-05 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-01-02 | 2020-02-05 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-02 | 2020-02-05 | N |
Provide activities to meet all resident's needs. | Health | 2020-01-02 | 2020-02-05 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-02 | 2020-02-05 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-02 | 2020-02-05 | 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 | 2020-01-02 | 2020-02-05 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-02 | 2020-02-05 | 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 | 2020-01-02 | 2020-02-05 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-02 | 2020-02-05 | N |
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2020-01-02 | 2020-02-05 | N |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-01-02 | 2020-02-05 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-01-02 | 2020-02-05 | N |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-01-02 | 2020-02-05 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-02 | 2020-02-05 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-17 | 2020-02-05 | 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 | 2019-12-17 | 2020-02-05 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-12-17 | 2020-02-05 | 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 | 2019-12-17 | 2020-02-05 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-17 | 2020-02-05 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-17 | 2020-02-05 | N |