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Deficiency Records for Zahav of Berwyn
A list of the most recent deficiencies for Zahav of Berwyn. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Zahav of Berwyn. 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 treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-16 | 2024-07-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-07-08 | 2024-07-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-08 | 2024-07-22 | 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 | 2024-07-08 | 2024-07-22 | Y |
| Have proper power supply for life support equipment. | Fire Safety | 2024-05-01 | 2024-07-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-01 | 2024-07-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-05-01 | 2024-07-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-01 | 2024-06-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-01 | 2024-06-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-04-25 | 2024-05-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-25 | 2024-05-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-25 | 2024-05-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-04-25 | 2024-05-07 | 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 | 2024-04-25 | 2024-05-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-25 | 2024-05-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-25 | 2024-05-07 | 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 | 2024-04-25 | 2024-05-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-25 | 2024-05-07 | Y |
| 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 | 2024-05-01 | 2024-05-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-01 | 2024-05-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-12 | 2024-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-12 | 2024-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-12 | 2024-04-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-30 | 2023-06-14 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2023-05-30 | 2023-06-14 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-05-30 | 2023-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-30 | 2023-06-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-19 | 2023-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-19 | 2023-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-19 | 2023-03-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-19 | 2023-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-05 | 2023-01-09 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-12-08 | 2022-12-22 | 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 | 2022-12-08 | 2022-12-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-08 | 2022-12-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-02 | 2022-12-14 | 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 | 2022-12-02 | 2022-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2022-12-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-02 | 2022-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2022-12-14 | 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 | 2022-12-02 | 2022-12-14 | 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 | 2022-11-10 | 2022-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-07 | 2022-08-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-29 | 2022-07-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-29 | 2022-07-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-07-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-29 | 2022-07-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-29 | 2022-07-15 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-06-29 | 2022-07-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-10 | 2022-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-10 | 2022-05-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-06 | 2022-04-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-06 | 2022-04-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-06 | 2022-04-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-13 | 2022-01-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-20 | 2022-01-29 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-12-19 | 2022-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-19 | 2022-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-01 | 2022-01-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-20 | 2021-12-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-20 | 2021-12-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-20 | 2021-12-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-20 | 2021-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-20 | 2021-11-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-20 | 2021-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-20 | 2021-11-24 | 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 | 2021-10-20 | 2021-11-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-10-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-01 | 2021-10-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-01 | 2021-10-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-01 | 2021-10-23 | 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 | 2021-10-01 | 2021-10-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-01 | 2021-10-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-01 | 2021-10-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-01 | 2021-10-23 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-10-01 | 2021-10-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-01 | 2021-10-23 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-02-10 | 2021-02-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-02-05 | 2021-02-18 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-02-05 | 2021-02-18 | 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 | 2021-02-05 | 2021-02-18 | N |
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