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Deficiency Records for Collingswood Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Collingswood Rehabilitation and Healthcare 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 Collingswood Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| 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 | 2022-12-07 | 2023-03-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-07 | 2023-03-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-07 | 2023-03-06 | Y |
| 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 | 2022-12-07 | 2023-03-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-07 | 2023-03-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-03-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-07 | 2023-01-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-07 | 2023-01-17 | 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 | 2022-12-07 | 2023-01-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-07 | 2023-01-17 | Y |
| 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 | 2022-08-23 | 2022-10-31 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-23 | 2022-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-23 | 2022-10-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-08-23 | 2022-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | Y |
| 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 | 2022-08-23 | 2022-10-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-23 | 2022-10-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-23 | 2022-10-31 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-23 | 2022-10-31 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-23 | 2022-10-31 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-23 | 2022-10-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-08-23 | 2022-10-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-23 | 2022-10-31 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-08-23 | 2022-10-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-23 | 2022-10-31 | 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 | 2022-08-23 | 2022-10-31 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-23 | 2022-10-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-23 | 2022-10-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-23 | 2022-10-31 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-23 | 2022-10-31 | Y |
| 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 | 2022-08-23 | 2022-10-31 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-23 | 2022-10-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-23 | 2022-10-31 | Y |
| Provide appropriate foot care. | Health | 2022-08-23 | 2022-10-31 | Y |
| 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 | 2022-08-23 | 2022-10-31 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-08 | 2022-09-27 | N |
| Meet other general requirements. | Fire Safety | 2020-01-07 | 2020-02-19 | 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 | 2020-01-07 | 2020-02-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-02-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-07 | 2020-02-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-07 | 2020-02-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-07 | 2020-02-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-07 | 2020-02-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-12-09 | 2020-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-09 | 2020-01-23 | 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 | 2019-12-09 | 2020-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-09 | 2020-01-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-12-09 | 2020-01-23 | 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 | 2019-12-09 | 2020-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-09 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-09 | 2020-01-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-12-09 | 2020-01-23 | N |
| Keep all essential equipment working safely. | Health | 2019-12-09 | 2020-01-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-01-03 | 2019-02-15 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2019-01-03 | 2019-02-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-03 | 2019-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-03 | 2019-02-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-08 | 2019-02-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-08 | 2019-02-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-08 | 2019-02-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-08 | 2019-02-11 | N |
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