A list of the most recent deficiencies for Rae Ann Suburban. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-19 | 2024-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-19 | 2024-03-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-29 | 2024-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2024-01-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-13 | 2024-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2024-01-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-13 | 2024-01-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-13 | 2024-01-02 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-23 | 2023-08-29 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-08-23 | 2023-08-29 | 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 | 2023-08-23 | 2023-08-29 | 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 | 2023-08-23 | 2023-08-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-23 | 2023-08-29 | Y |
| Have policies on smoking. | Health | 2023-08-23 | 2023-08-29 | 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 | 2023-08-02 | 2023-08-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-02 | 2023-08-03 | 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 | 2023-05-19 | 2023-05-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-19 | 2023-05-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-19 | 2023-05-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-19 | 2023-05-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-23 | 2023-03-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-23 | 2023-03-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-23 | 2023-03-31 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-08 | 2022-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-08 | 2022-08-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-03 | 2022-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-08-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-03 | 2022-08-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-03 | 2022-08-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-10 | 2021-09-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-19 | 2021-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-19 | 2021-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-19 | 2021-06-08 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-06 | 2019-10-18 | 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 | 2019-08-06 | 2019-10-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-06 | 2019-10-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-06 | 2019-10-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-08 | 2019-10-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-08 | 2019-10-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-08-08 | 2019-10-02 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2018-06-27 | 2018-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-28 | 2018-08-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-28 | 2018-08-01 | 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 | 2018-06-28 | 2018-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-28 | 2018-08-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-06-27 | 2018-08-01 | N |
