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Deficiency Records for Edwardsville Care and Rehab
A list of the most recent deficiencies for Edwardsville Care and Rehab. 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 Edwardsville Care and Rehab. 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-05-17 | 2023-06-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-17 | 2023-06-12 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-18 | 2023-03-09 | 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 | 2023-01-18 | 2023-03-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-18 | 2023-03-09 | 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 | 2023-01-18 | 2023-03-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-03-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-28 | 2023-02-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-28 | 2023-02-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-28 | 2023-02-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-28 | 2023-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-28 | 2023-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-28 | 2023-02-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-28 | 2023-02-03 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-28 | 2023-02-03 | Y |
| 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 | 2022-12-28 | 2023-02-03 | 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 | 2022-12-28 | 2023-02-03 | 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 | 2022-12-28 | 2023-02-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-28 | 2023-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-25 | 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 | 2022-08-25 | 2022-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-29 | 2022-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-03 | 2022-02-10 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-16 | 2021-08-03 | 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 | 2021-06-16 | 2021-08-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-16 | 2021-08-03 | 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 | 2021-06-16 | 2021-08-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-16 | 2021-08-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-13 | 2021-06-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-05-13 | 2021-06-10 | N |
| 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 | 2021-05-13 | 2021-06-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-13 | 2021-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-13 | 2021-06-10 | 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 | 2021-05-13 | 2021-06-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-13 | 2021-06-10 | 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 | 2021-05-13 | 2021-06-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-05-13 | 2021-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-13 | 2021-06-10 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-13 | 2021-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-06-10 | 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 | 2019-10-10 | 2019-10-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-10 | 2019-10-30 | 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 | 2019-10-10 | 2019-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-10-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-10 | 2019-10-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-10 | 2019-10-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-11 | 2019-08-10 | 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 | 2019-07-11 | 2019-08-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-11 | 2019-08-10 | 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 | 2019-07-11 | 2019-08-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-11 | 2019-08-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-11 | 2019-07-11 | N |
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