Deficiency Records for Falls Run Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Falls Run Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-03-22 | 2023-05-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-16 | 2023-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-04-14 | 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 | 2023-03-16 | 2023-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-04-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-16 | 2023-04-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-16 | 2023-04-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-16 | 2023-04-14 | 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 | 2023-03-16 | 2023-04-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2022-03-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-26 | 2021-09-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-26 | 2021-09-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-26 | 2021-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-26 | 2021-09-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-26 | 2021-09-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-08-26 | 2021-09-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-26 | 2021-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-26 | 2021-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-29 | 2021-05-17 | Y |
| 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 | 2019-09-06 | 2019-10-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-06 | 2019-10-01 | 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 | 2019-09-06 | 2019-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-06 | 2019-10-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-06 | 2019-10-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-06 | 2019-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-06 | 2019-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-06 | 2019-10-01 | 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 | 2019-09-06 | 2019-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-06 | 2019-10-01 | 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 | 2019-09-10 | 2019-10-01 | 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 | 2019-09-10 | 2019-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-10 | 2019-10-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-10 | 2019-10-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-09-10 | 2019-10-01 | N |
