A list of the most recent deficiencies for Concordia at Rebecca Residence. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-30 | 2023-08-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-30 | 2023-08-21 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-06-30 | 2023-08-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-30 | 2023-08-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-08-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-30 | 2023-08-21 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-30 | 2023-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-08-21 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-06-30 | 2023-08-21 | 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 | 2023-06-30 | 2023-08-21 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-03 | 2023-08-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-03 | 2023-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-02-13 | 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 | 2022-09-22 | 2022-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-22 | 2022-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-22 | 2022-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-22 | 2022-11-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-25 | 2022-08-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-04 | 2022-05-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-01 | 2021-04-30 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-03-31 | 2021-04-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-03-31 | 2021-04-09 | N |
