Deficiency Records for Kendall House Wellness and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Kendall House Wellness 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 generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-07 | 2023-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-18 | 2023-10-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-10-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-08 | 2023-09-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-08 | 2023-09-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-08 | 2023-09-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-08 | 2023-09-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-08 | 2023-09-11 | 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 | 2023-09-08 | 2023-09-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-09-11 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-09-08 | 2023-09-11 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-09-08 | 2023-09-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-15 | 2022-08-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-07-15 | 2022-07-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-15 | 2022-07-18 | N |
| Post nurse staffing information every day. | Health | 2022-07-15 | 2022-07-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-15 | 2022-07-18 | 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 | 2022-07-15 | 2022-07-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-04-20 | 2021-05-13 | 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 | 2021-04-22 | 2021-05-12 | N |
| Post nurse staffing information every day. | Health | 2021-04-22 | 2021-05-12 | 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 | 2021-04-22 | 2021-05-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-04-22 | 2021-05-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-22 | 2021-05-12 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-20 | 2021-04-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-20 | 2021-04-21 | N |
