A list of the most recent deficiencies for Hennessey Nursing 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-06 | 2023-08-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-07-06 | 2023-08-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-06 | 2023-08-14 | 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 | 2023-07-06 | 2023-08-14 | 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 | 2023-07-06 | 2023-08-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-07-06 | 2023-08-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-06 | 2023-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-06 | 2023-08-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-08 | 2023-06-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-07 | 2022-01-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-07 | 2022-01-02 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-02 | 2022-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-02 | 2022-01-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-02 | 2022-01-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-31 | 2019-09-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-31 | 2019-09-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-07-31 | 2019-09-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-31 | 2019-09-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-31 | 2019-09-03 | 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 | 2019-07-31 | 2019-09-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-31 | 2019-09-03 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-07-31 | 2019-09-03 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-07-31 | 2019-09-03 | 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 | 2019-07-31 | 2019-09-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
