Deficiency Records for Lea Hill Rehabilitation and Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lea Hill Rehabilitation and Care Center. 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 | 2023-04-03 | 2023-05-15 | 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 | 2023-04-03 | 2023-05-15 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-03 | 2023-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-03 | 2023-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-03 | 2023-05-15 | 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 | 2023-04-03 | 2023-05-15 | 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 | 2023-04-03 | 2023-05-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-03 | 2023-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-03 | 2023-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-03 | 2023-05-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-28 | 2023-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-22 | Y |
| Report COVID19 data to residents and families. | Health | 2022-08-10 | 2022-09-22 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-10 | 2022-09-22 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-09 | 2022-01-19 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-12-09 | 2022-01-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-09 | 2022-01-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-09 | 2022-01-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-12-09 | 2022-01-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| 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 | 2021-12-09 | 2022-01-19 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-12-09 | 2022-01-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-09 | 2022-01-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-09 | 2022-01-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-09 | 2022-01-19 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-12 | 2021-11-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-07 | 2019-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-07 | 2019-09-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-07 | 2019-09-23 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-07 | 2019-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-07 | 2019-09-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-08-07 | 2019-09-23 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-08-07 | 2019-09-23 | 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 | 2019-08-07 | 2019-09-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-06 | 2019-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-06 | 2019-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-06 | 2019-08-30 | N |
