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Deficiency Records for Seven Hills Health and Rehab Center
A list of the most recent deficiencies for Seven Hills Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Seven Hills Health and Rehab 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-24 | 2023-11-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-24 | 2023-11-24 | 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 | 2023-10-24 | 2023-11-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-24 | 2023-11-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-07-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-04 | 2023-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-27 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-03-07 | 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 | 2022-09-19 | 2022-10-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-19 | 2022-10-18 | N |
| Provide appropriate foot care. | Health | 2022-09-19 | 2022-10-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-19 | 2022-10-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-19 | 2022-10-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-19 | 2022-10-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-19 | 2022-10-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-19 | 2022-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-19 | 2022-10-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-13 | 2022-10-18 | 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 | 2022-09-13 | 2022-10-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-13 | 2022-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-06-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-09 | 2019-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-09 | 2019-09-27 | 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 | 2019-09-09 | 2019-09-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-09 | 2019-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-09 | 2019-09-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-03 | 2019-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-09 | 2018-09-05 | 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 | 2018-08-09 | 2018-09-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-09 | 2018-09-05 | 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 | 2018-08-08 | 2018-09-05 | 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 | 2018-08-08 | 2018-09-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-08 | 2018-09-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-08 | 2018-09-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-08 | 2018-09-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-08-08 | 2018-09-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-08 | 2018-09-05 | N |
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