A list of the most recent deficiencies for Denison 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-09 | 2023-11-10 | Y |
| 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 | 2023-07-13 | 2023-07-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-15 | 2023-03-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-15 | 2023-03-13 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-02-15 | 2023-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-15 | 2023-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-15 | 2023-03-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-15 | 2023-03-01 | 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 | 2023-02-15 | 2023-02-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-15 | 2023-02-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-16 | 2023-02-17 | N |
| Keep all essential equipment working safely. | Health | 2022-07-26 | 2022-08-31 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-26 | 2022-08-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-16 | 2022-02-23 | Y |
| 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 | 2021-12-15 | 2022-01-18 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-15 | 2022-01-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-15 | 2022-01-18 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-12-15 | 2022-01-18 | Y |
| Provide large enough exits. | Fire Safety | 2021-12-14 | 2022-01-18 | 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 | 2021-12-14 | 2022-01-18 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-12-14 | 2022-01-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-15 | 2021-12-18 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-12-15 | 2021-12-16 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-09-03 | 2020-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-03 | 2020-10-03 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2020-09-03 | 2020-10-03 | 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 | 2020-09-03 | 2020-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-02 | 2020-10-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-09-02 | Not Fixed | N |
