Deficiency Records for Old Dominion Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Old Dominion Rehabilitation and Nursing. 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 proper backup exit lighting. | Fire Safety | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-07 | 2022-08-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-07 | 2022-08-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-07 | 2022-08-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-06 | 2022-07-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-06 | 2022-07-11 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-06 | 2022-07-11 | Y |
| 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 | 2022-06-06 | 2022-07-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-06 | 2022-07-11 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-06 | 2022-07-11 | 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 | 2022-06-06 | 2022-07-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-06 | 2022-07-11 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-06 | 2022-07-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-03 | 2022-04-16 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-03 | 2022-04-16 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-03-03 | 2022-04-16 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-03 | 2022-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-04-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-03 | 2022-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-03-03 | 2022-04-16 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-03-03 | 2022-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-04-16 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-03 | 2022-04-16 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-03 | 2022-04-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-03 | 2022-04-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-03 | 2022-04-16 | 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 | 2022-03-03 | 2022-04-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish methods for sharing information. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-03 | 2022-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-18 | 2019-05-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-18 | 2019-05-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-03-01 | 2019-04-12 | 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 | 2019-03-01 | 2019-04-12 | 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 | 2019-03-01 | 2019-04-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-01 | 2019-04-12 | 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 | 2019-03-01 | 2019-04-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-01 | 2019-04-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-01 | 2019-04-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-01 | 2019-04-12 | N |
| Provide appropriate foot care. | Health | 2019-03-01 | 2019-04-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-01 | 2019-04-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-01 | 2019-04-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-01 | 2019-04-12 | N |
| Provide or obtain dental services for each resident. | Health | 2019-03-01 | 2019-04-12 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2019-03-01 | 2019-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-01 | 2019-04-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish methods for sharing information. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-03-01 | 2019-04-12 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2017-09-28 | 2017-10-28 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-09-28 | 2017-10-28 | N |
| Provide housekeeping and maintenance services. | Health | 2017-09-28 | 2017-10-28 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-28 | 2017-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-28 | 2017-10-28 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-28 | 2017-10-28 | N |
| Dispose of garbage and refuse properly. | Health | 2017-09-28 | 2017-10-28 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-28 | 2017-10-28 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-28 | 2017-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-09-28 | 2017-10-28 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-28 | 2017-10-28 | N |
