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Deficiency Records for Spencer Post Acute Rehabilitation Center
A list of the most recent deficiencies for Spencer Post Acute Rehabilitation Center. 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 Spencer Post Acute Rehabilitation 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-27 | 2024-09-27 | N |
| Use approved construction type or materials. | Fire Safety | 2024-08-27 | 2024-09-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-27 | 2024-09-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-27 | 2024-09-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-27 | 2024-09-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-27 | 2024-09-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-27 | 2024-09-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-22 | 2024-09-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-22 | 2024-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-22 | 2024-09-12 | 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 | 2024-08-22 | 2024-09-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-22 | 2024-09-12 | 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 | 2024-08-22 | 2024-09-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-08-22 | 2024-09-12 | N |
| Post nurse staffing information every day. | Health | 2024-08-22 | 2024-09-12 | 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 | 2024-08-22 | 2024-09-12 | 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 | 2024-08-22 | 2024-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-22 | 2024-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-22 | 2024-09-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-08-27 | 2024-09-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-08-27 | 2024-09-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-08-27 | 2024-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-27 | 2024-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-27 | 2024-09-12 | 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 | 2024-08-27 | 2024-09-11 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-08-27 | 2024-09-09 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-05-20 | 2024-05-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-14 | 2024-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-14 | 2024-04-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-14 | 2024-04-12 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-02 | 2023-12-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-30 | 2023-11-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-30 | 2023-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-30 | 2023-11-22 | 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 | 2023-10-30 | 2023-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-30 | 2023-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-30 | 2023-11-22 | 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 | 2023-10-30 | 2023-11-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-30 | 2023-11-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-30 | 2023-11-22 | 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 | 2023-10-30 | 2023-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-30 | 2023-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-30 | 2023-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-02 | 2023-11-15 | 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 | 2023-11-02 | 2023-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-02 | 2023-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-02 | 2023-11-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-02 | 2023-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-02 | 2023-11-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-30 | 2023-11-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-02 | 2023-11-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-07-13 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-11 | 2022-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-05-06 | 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 | 2022-04-07 | 2022-05-06 | N |
| Post nurse staffing information every day. | Health | 2022-04-07 | 2022-05-06 | 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 | 2022-04-07 | 2022-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-05-06 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-07 | 2022-05-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-04-11 | 2022-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-11 | 2022-04-11 | N |
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