A list of the most recent deficiencies for Alcester Care and Rehab Center, Inc. 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-26 | 2023-11-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-26 | 2023-11-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-26 | 2023-11-10 | Y |
| 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 | 2023-06-06 | 2023-06-23 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-08 | 2023-05-17 | 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 | 2023-03-09 | 2023-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-09 | 2023-04-15 | 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 | 2023-03-09 | 2023-04-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-09 | 2023-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-04-15 | 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 | 2023-03-08 | 2023-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-04-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-11-04 | 2021-12-04 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-04 | 2021-12-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-11-04 | 2021-12-04 | 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 | 2021-11-04 | 2021-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2021-12-04 | 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 | 2021-11-04 | 2021-12-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-04 | 2021-12-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-04 | 2021-12-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-04 | 2021-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2021-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-12-04 | N |
| Report COVID19 data to residents and families. | Health | 2021-11-04 | 2021-12-04 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-04 | 2021-12-04 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-22 | 2019-10-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-22 | 2019-10-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-22 | 2019-10-11 | 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 | 2019-08-22 | 2019-10-11 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-08-22 | 2019-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-10-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-20 | 2019-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-20 | 2019-09-30 | 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 | 2019-08-20 | 2019-09-09 | N |
