Deficiency Records for North Strabane Rehabilitation and Wellness Ctr, Ll
Updated as of March 01, 2024
A list of the most recent deficiencies for North Strabane Rehabilitation and Wellness Ctr, Ll. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-10 | 2023-11-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-10-31 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-06-21 | 2023-07-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-02 | 2022-12-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-12-02 | 2022-12-22 | 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 | 2022-12-02 | 2022-12-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-02 | 2022-12-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-02 | 2022-12-22 | N |
| Respond appropriately to all alleged violations. | Health | 2022-12-02 | 2022-12-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-02 | 2022-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2022-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-02 | 2022-12-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2022-12-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-02 | 2022-12-22 | 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 | 2022-12-02 | 2022-12-22 | 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 | 2022-12-02 | 2022-12-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-02 | 2022-12-22 | 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 | 2022-12-02 | 2022-12-22 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-02 | 2022-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-01 | 2022-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-01 | 2022-12-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-12-01 | 2022-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-01 | 2022-12-19 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2022-11-15 | 2022-12-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-01 | 2022-03-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-10 | 2021-12-27 | 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 | 2021-11-10 | 2021-12-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-11-10 | 2021-12-27 | 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 | 2021-11-10 | 2021-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-10 | 2021-12-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-10 | 2021-12-27 | 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 | 2021-11-10 | 2021-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-10 | 2021-12-27 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-15 | 2021-12-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-26 | 2021-06-30 | Y |
