A list of the most recent deficiencies for Roo Lan Health and Rehab. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-10-18 | 2023-11-03 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-10-18 | 2023-11-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-18 | 2023-11-03 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-25 | 2023-07-06 | 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 | 2023-05-25 | 2023-07-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-25 | 2023-07-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-25 | 2023-07-06 | 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 | 2023-05-25 | 2023-07-06 | N |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-07-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-25 | 2023-07-06 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-05-25 | 2023-07-06 | 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 | 2023-05-25 | 2023-07-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-25 | 2023-07-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-25 | 2023-07-06 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-23 | 2023-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-06-13 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-23 | 2023-06-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-23 | 2023-06-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-29 | 2023-04-10 | Y |
| 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 | 2023-02-15 | 2023-03-03 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-15 | 2023-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-15 | 2023-03-03 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-12-12 | 2023-01-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-12 | 2023-01-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-10 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-30 | 2023-01-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2023-01-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-30 | 2023-01-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-03-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-27 | 2022-03-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-03-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-27 | 2022-03-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-03-09 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-28 | 2022-03-09 | Y |
| Provide appropriate foot care. | Health | 2021-10-02 | 2021-11-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-19 | 2021-10-03 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-08-19 | 2021-10-03 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-08-19 | 2021-10-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-19 | 2021-10-03 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-08-19 | 2021-10-03 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-08-19 | 2021-10-03 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-19 | 2021-10-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-08-19 | 2021-10-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-08-19 | 2021-10-03 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-08-19 | 2021-10-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-19 | 2021-10-03 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-19 | 2021-10-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-08-19 | 2021-10-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-10-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-10-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-19 | 2021-10-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-19 | 2021-10-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-08-19 | 2021-10-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-19 | 2021-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2021-08-19 | 2021-10-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-08-19 | 2021-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-10-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-10-03 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-08-19 | 2021-10-03 | Y |
| Post nurse staffing information every day. | Health | 2021-08-19 | 2021-10-03 | 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 | 2021-08-19 | 2021-10-03 | Y |
| Meet other general requirements. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-08-03 | 2021-08-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-29 | 2021-07-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-31 | 2021-04-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-31 | 2021-04-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-13 | 2019-04-22 | 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 | 2019-02-13 | 2019-04-22 | 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 | 2019-02-13 | 2019-04-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-02-13 | 2019-04-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-13 | 2019-04-22 | 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 | 2019-02-13 | 2019-04-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-13 | 2019-04-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-13 | 2019-04-22 | N |
| Provide activities to meet all resident's needs. | Health | 2019-02-13 | 2019-04-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-13 | 2019-04-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-13 | 2019-04-22 | 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 | 2019-02-13 | 2019-04-22 | 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 | 2019-02-13 | 2019-04-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-13 | 2019-04-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-13 | 2019-04-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-02-13 | 2019-04-22 | 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 | 2019-02-13 | 2019-03-20 | 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 | 2019-02-13 | 2019-03-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-13 | 2019-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-13 | 2019-02-13 | N |
