Deficiency Records for Divine Rehabilitation and Nursing at Sylvania
Updated as of April 01, 2024
A list of the most recent deficiencies for Divine Rehabilitation and Nursing at Sylvania. 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? |
|---|---|---|---|---|
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-11-06 | 2024-01-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-06 | 2024-01-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-10 | 2024-01-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-16 | 2024-01-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-16 | 2024-01-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-16 | 2024-01-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-11-16 | 2024-01-05 | N |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-16 | 2024-01-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-16 | 2024-01-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-16 | 2024-01-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2024-01-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-16 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-16 | 2024-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2024-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-16 | 2024-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-16 | 2024-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-16 | 2024-01-05 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-11-16 | 2024-01-05 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | 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 | 2023-11-16 | 2024-01-05 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-16 | 2024-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2024-01-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-16 | 2024-01-05 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-11-16 | 2024-01-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-16 | 2024-01-05 | 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 | 2023-11-15 | 2024-01-05 | 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 | 2023-11-15 | 2024-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-15 | 2024-01-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-25 | 2023-11-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-08-25 | 2023-11-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-10 | 2023-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-14 | 2022-11-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-30 | 2022-01-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-15 | 2021-09-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-15 | 2021-09-30 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-07-15 | 2021-09-30 | 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 | 2021-07-15 | 2021-09-30 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-15 | 2021-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-15 | 2021-09-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-15 | 2021-09-30 | N |
| Post nurse staffing information every day. | Health | 2021-07-15 | 2021-09-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-15 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-09-30 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2021-07-15 | 2021-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-15 | 2021-09-30 | 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 | 2021-07-20 | 2021-09-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-20 | 2021-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-20 | 2021-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-20 | 2021-09-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-28 | 2019-05-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-28 | 2019-05-24 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-03-28 | 2019-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-28 | 2019-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-28 | 2019-05-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-28 | 2019-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-28 | 2019-05-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-26 | 2019-05-24 | 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 | 2019-03-26 | 2019-05-24 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-26 | 2019-05-24 | N |
