Deficiency Records for Soundview Rehabilitation and Health Care Inc
Updated as of March 01, 2024
A list of the most recent deficiencies for Soundview Rehabilitation and Health Care Inc. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-18 | 2024-02-15 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-06-02 | 2023-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-02 | 2023-06-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-02 | 2023-06-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-13 | 2023-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-13 | 2023-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-13 | 2023-04-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-13 | 2023-04-25 | N |
| Develop a communication plan. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-14 | Y |
| 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 | 2022-12-07 | 2023-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-09-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-18 | 2022-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-18 | 2022-08-31 | Y |
| 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 | 2022-07-18 | 2022-08-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-07 | 2022-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-08-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-07 | 2022-08-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-11 | 2022-04-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-11 | 2022-04-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-11 | 2022-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-28 | 2022-01-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-03 | 2021-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-03 | 2021-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-03 | 2021-12-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-03 | 2021-12-28 | 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 | 2021-12-03 | 2021-12-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-03 | 2021-12-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-05 | 2021-09-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-07 | Y |
| 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 | 2021-08-05 | 2021-08-27 | Y |
| 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 | 2021-06-07 | 2021-06-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-06 | 2019-12-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-06 | 2019-12-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Post nurse staffing information every day. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-11-06 | 2019-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-06 | 2019-12-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-06 | 2019-12-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-06 | 2019-12-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-11 | 2019-03-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-01-11 | 2019-03-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-11 | 2019-03-19 | 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 | 2019-01-11 | 2019-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-11 | 2019-03-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-01-11 | 2019-03-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-01-11 | 2019-03-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-01-04 | 2019-02-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-04 | 2019-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-04 | 2019-02-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-04 | 2019-02-01 | N |
