Deficiency Records for Agility Health and Rehabilitation
Updated as of October 01, 2020
This is not the most recent data for Agility Health and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Agility Health 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 properly located and lighted "Exit" signs. | Fire Safety | 2020-03-17 | 2020-04-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-05 | 2020-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-02-05 | 2020-03-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-05 | 2020-03-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-05 | 2020-03-03 | 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 | 2020-02-05 | 2020-03-03 | 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 | 2020-02-05 | 2020-03-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-05 | 2020-03-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-05 | 2020-03-03 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2020-02-05 | 2020-03-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-05 | 2020-03-03 | Y |
| 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 | 2019-11-21 | 2019-11-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-21 | 2019-11-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-21 | 2019-11-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-21 | 2019-11-19 | 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 | 2019-10-21 | 2019-11-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-21 | 2019-11-19 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-23 | 2019-11-01 | 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 | 2019-09-23 | 2019-11-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-23 | 2019-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-23 | 2019-11-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-23 | 2019-11-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-23 | 2019-11-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-23 | 2019-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-23 | 2019-11-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-23 | 2019-11-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-23 | 2019-11-01 | 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 | 2019-09-23 | 2019-11-01 | 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 | 2019-09-23 | 2019-11-01 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-23 | 2019-11-01 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-09-23 | 2019-11-01 | Y |
| Have policies on smoking. | Health | 2019-07-29 | 2019-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-17 | 2019-07-02 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-03-22 | 2019-04-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-22 | 2019-04-16 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2019-03-22 | 2019-04-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-11 | 2019-04-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-11 | 2019-04-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-02-08 | 2019-03-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-08 | 2019-03-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-05 | 2019-02-05 | 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 | 2018-12-14 | 2019-01-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-14 | 2019-01-10 | 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 | 2018-12-14 | 2019-01-10 | 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 | 2018-12-14 | 2019-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-14 | 2019-01-10 | 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 | 2018-12-14 | 2019-01-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-12-14 | 2019-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-14 | 2019-01-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-05 | 2019-01-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-12-05 | 2019-01-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-05 | 2019-01-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-05 | 2019-01-07 | 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 | 2018-12-05 | 2019-01-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-12-05 | 2019-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-07 | 2019-01-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-01 | 2018-11-30 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-07-19 | 2018-08-10 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Establish methods for sharing information. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2017-12-20 | 2018-01-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-12-20 | 2018-01-15 | 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 | 2017-12-20 | 2018-01-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2017-12-20 | 2018-01-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-20 | 2018-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-20 | 2018-01-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2017-12-20 | 2018-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-20 | 2018-01-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2017-12-20 | 2018-01-15 | N |
| Provide or obtain dental services for each resident. | Health | 2017-12-20 | 2018-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-20 | 2018-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-20 | 2018-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-08 | 2018-01-15 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2017-12-12 | 2018-01-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-12-12 | 2018-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-12 | 2018-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-12-12 | 2018-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-12-12 | 2018-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-12-12 | 2018-01-03 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-01-12 | 2017-02-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-01-12 | 2017-02-27 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-01-12 | 2017-02-27 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-01-12 | 2017-02-27 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-01-12 | 2017-02-27 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-01-12 | 2017-02-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-01-12 | 2017-02-27 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-12 | 2017-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-01-12 | 2017-02-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-01-12 | 2017-02-27 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-12 | 2017-02-27 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-01-12 | 2017-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-01-12 | 2017-02-27 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-01-12 | 2017-02-27 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-01-12 | 2017-02-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-12 | 2017-02-27 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-01-12 | 2017-02-27 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-01-12 | 2017-02-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-12 | 2017-02-27 | N |
| Keep all essential equipment working safely. | Health | 2017-01-12 | 2017-02-27 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-01-12 | 2017-02-27 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-01-12 | 2017-02-27 | N |
| Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. | Health | 2017-01-12 | 2017-02-27 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-12 | 2017-02-27 | 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 | 2017-01-12 | 2017-02-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-01-12 | 2017-02-27 | N |
