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Deficiency Records for Atlee Hill Health and Rehab Center
A list of the most recent deficiencies for Atlee Hill Health and Rehab 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 Atlee Hill Health and Rehab 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-02 | 2024-03-19 | 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 | 2024-01-02 | 2024-03-19 | 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 | 2024-01-02 | 2024-03-19 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-12-21 | 2024-02-14 | N |
| 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 | 2023-12-21 | 2024-02-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-21 | 2024-02-14 | N |
| 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 | 2023-12-21 | 2024-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-21 | 2024-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-21 | 2024-02-14 | 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 | 2023-12-21 | 2024-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-02-14 | 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 | 2023-12-21 | 2024-02-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-21 | 2024-02-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-21 | 2024-02-14 | 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 | 2023-12-21 | 2024-02-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-21 | 2024-02-14 | 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 | 2023-12-21 | 2024-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-02-14 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-21 | 2024-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-02-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-12-21 | 2024-02-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-21 | 2024-02-14 | 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 | 2023-12-21 | 2024-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-21 | 2023-12-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-19 | 2019-06-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-19 | 2019-06-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-19 | 2019-06-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-19 | 2019-06-24 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-04-19 | 2019-06-24 | N |
| 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 | 2019-04-19 | 2019-06-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-19 | 2019-06-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-19 | 2019-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-19 | 2019-06-24 | 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 | 2019-04-19 | 2019-06-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-19 | 2019-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-19 | 2019-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-19 | 2019-06-24 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-04-19 | 2019-06-24 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-19 | 2019-06-24 | N |
| Post nurse staffing information every day. | Health | 2019-04-19 | 2019-06-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-19 | 2019-06-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-19 | 2019-06-24 | 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 | 2019-04-19 | 2019-06-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-19 | 2019-06-24 | 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 | 2019-04-19 | 2019-06-24 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-19 | 2019-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-19 | 2019-06-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-19 | 2019-06-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-19 | 2019-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-19 | 2019-06-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-19 | 2019-06-24 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-11-16 | 2018-01-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-11-16 | 2018-01-09 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-11-16 | 2018-01-09 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-11-16 | 2018-01-09 | N |
| Give notice to the resident before a room or roommate change. | Health | 2017-11-16 | 2018-01-09 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-11-16 | 2018-01-09 | N |
| Provide housekeeping and maintenance services. | Health | 2017-11-16 | 2018-01-09 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-11-16 | 2018-01-09 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-11-16 | 2018-01-09 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-11-16 | 2018-01-09 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-16 | 2018-01-09 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-11-16 | 2018-01-09 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-16 | 2018-01-09 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-16 | 2018-01-09 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-16 | 2018-01-09 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-11-16 | 2018-01-09 | N |
| Make sure that doctors visit residents regularly, as required. | Health | 2017-11-16 | 2018-01-09 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-11-16 | 2018-01-09 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-16 | 2018-01-09 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-16 | 2018-01-09 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-11-16 | 2018-01-09 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-11-16 | 2018-01-09 | N |
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