Deficiency Records for Henrico Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Henrico Health and Rehabilitation 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 | 2024-01-26 | 2024-02-09 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-01-26 | 2024-02-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-26 | 2024-02-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-07 | 2024-01-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-07 | 2024-01-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-04 | 2024-01-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-04 | 2024-01-12 | Y |
| 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 | 2023-10-04 | 2023-11-19 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-10-04 | 2023-11-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-04 | 2023-11-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-10-04 | 2023-11-19 | 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 | 2023-10-04 | 2023-11-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-04 | 2023-11-19 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-10-04 | 2023-11-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-10-04 | 2023-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-04 | 2023-11-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-04 | 2023-11-19 | 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 | 2023-10-04 | 2023-11-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-04 | 2023-11-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-04 | 2023-11-19 | 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 | 2023-10-04 | 2023-11-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-04 | 2023-11-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-04 | 2023-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-04 | 2023-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-04 | 2023-11-19 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-10-04 | 2023-11-19 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-04 | 2023-11-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-04 | 2023-11-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-04 | 2023-11-19 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-04 | 2023-11-19 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-04 | 2023-11-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-04 | 2023-11-19 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-04 | 2023-11-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-04 | 2023-11-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-04 | 2023-11-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-04 | 2023-11-19 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-10-04 | 2023-11-19 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-25 | 2023-08-15 | 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 | 2023-03-15 | 2023-03-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-26 | 2023-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-26 | 2023-02-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-26 | 2023-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-26 | 2023-02-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-26 | 2023-02-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-26 | 2023-02-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-02-28 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-02-28 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-26 | 2023-02-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-15 | 2022-11-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-29 | 2022-05-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-29 | 2022-05-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-29 | 2022-05-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-29 | 2022-05-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-29 | 2022-05-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-29 | 2022-05-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-10 | 2022-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2022-01-12 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-10 | 2022-01-12 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-10 | 2022-01-12 | 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 | 2021-09-10 | 2022-01-12 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-09-10 | 2021-11-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-09-10 | 2021-11-30 | 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 | 2021-09-10 | 2021-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-10 | 2021-11-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-10 | 2021-11-30 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-09-10 | 2021-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-10 | 2021-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-20 | 2021-10-04 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-09-20 | 2021-10-04 | N |
| Use approved construction type or materials. | Fire Safety | 2018-11-02 | 2019-03-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-02 | 2019-03-28 | N |
| Meet other general requirements. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-02 | 2019-01-14 | 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 | 2018-11-02 | 2019-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-02 | 2019-01-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-25 | 2018-11-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-25 | 2018-11-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-25 | 2018-11-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-25 | 2018-11-23 | 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 | 2018-10-25 | 2018-11-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-25 | 2018-11-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-10-25 | 2018-11-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-25 | 2018-11-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-25 | 2018-11-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-11-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-10-25 | 2018-11-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-25 | 2018-11-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-25 | 2018-11-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-25 | 2018-11-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-10-25 | 2018-11-23 | N |
