A list of the most recent deficiencies for Waterside Health and Rehab Center. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-29 | 2023-08-03 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-06-29 | 2023-08-03 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-06-29 | 2023-08-03 | N |
| 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 | 2023-06-23 | 2023-07-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-23 | 2023-07-13 | 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 | 2023-06-23 | 2023-07-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-23 | 2023-07-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-23 | 2023-07-13 | 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 | 2023-06-23 | 2023-07-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-23 | 2023-07-13 | 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 | 2023-06-23 | 2023-07-13 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-23 | 2023-07-13 | 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 | 2023-06-23 | 2023-07-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-23 | 2023-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-23 | 2023-07-13 | Y |
| 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 | 2022-06-29 | 2022-08-04 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-12-12 | 2020-01-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-12 | 2020-01-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-12 | 2020-01-07 | N |
| 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 | 2019-12-12 | 2020-01-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-12 | 2020-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-07 | 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 | 2019-12-12 | 2020-01-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-12 | 2020-01-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-12 | 2020-01-07 | N |
| Provide appropriate foot care. | Health | 2019-12-12 | 2020-01-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-12 | 2020-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-01-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-12 | 2020-01-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-12 | 2019-12-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-12 | 2018-08-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-28 | 2018-08-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-28 | 2018-08-12 | 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 | 2018-06-28 | 2018-08-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-06-28 | 2018-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-28 | 2018-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-28 | 2018-08-12 | 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 | 2018-06-28 | 2018-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-28 | 2018-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-28 | 2018-08-12 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-06-28 | 2018-08-12 | 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 | 2018-06-28 | 2018-08-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-06-28 | 2018-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-28 | 2018-08-12 | 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 | 2018-06-28 | 2018-08-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-06-28 | 2018-08-12 | 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 | 2018-06-28 | 2018-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-28 | 2018-08-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-06-28 | 2018-08-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-06-28 | 2018-08-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-06-28 | 2018-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-10 | Not Fixed | N |
