A list of the most recent deficiencies for Fernhill Rehabilitation and Care. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-01 | 2023-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-04-26 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-15 | 2023-02-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-15 | 2023-02-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-15 | 2023-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-15 | 2023-02-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-15 | 2023-02-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-20 | 2023-01-09 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-20 | 2023-01-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-20 | 2023-01-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-20 | 2023-01-09 | 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 | 2022-12-20 | 2023-01-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-20 | 2023-01-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-20 | 2023-01-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-20 | 2023-01-09 | 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 | 2022-12-20 | 2023-01-09 | 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 | 2022-12-20 | 2023-01-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-20 | 2023-01-09 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-12-20 | 2023-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-01-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-20 | 2023-01-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-20 | 2023-01-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-20 | 2023-01-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-19 | 2021-05-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-11-20 | 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 | 2019-09-27 | 2019-11-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-27 | 2019-11-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-09-27 | 2019-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-27 | 2019-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-01 | 2019-11-08 | 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 | 2019-10-01 | 2019-11-08 | 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 | 2019-10-01 | 2019-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-01 | 2019-11-08 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Develop a communication plan. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-30 | 2018-03-27 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-02-06 | 2018-03-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-06 | 2018-03-13 | 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 | 2018-02-06 | 2018-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-06 | 2018-03-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-06 | 2018-03-13 | 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 | 2018-02-06 | 2018-03-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-02-06 | 2018-03-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-06 | 2018-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-06 | 2018-03-13 | 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 | 2018-02-06 | 2018-03-13 | 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 | 2018-02-06 | 2018-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-06 | 2018-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-06 | 2018-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-06 | 2018-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-06 | 2018-02-06 | N |
