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Deficiency Records for Williamstown Commons Nursing and Rehab
A list of the most recent deficiencies for Williamstown Commons Nursing 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 Williamstown Commons Nursing 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-11-06 | 2024-01-05 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-11-06 | 2024-01-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-06 | 2024-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-06 | 2024-01-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-06 | 2024-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-06 | 2024-01-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-24 | 2023-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-24 | 2023-11-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-24 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-24 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-24 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-22 | 2023-10-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-09 | 2023-09-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-18 | 2022-12-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-18 | 2022-11-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-18 | 2022-11-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-18 | 2022-11-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-18 | 2022-11-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-18 | 2022-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-18 | 2022-11-18 | 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 | 2022-10-18 | 2022-11-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-18 | 2022-11-18 | 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 | 2022-10-18 | 2022-11-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-18 | 2022-11-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-18 | 2022-11-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-26 | 2022-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-26 | 2022-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-26 | 2022-11-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-29 | 2022-10-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-11-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-09 | 2020-01-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-09 | 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 | 2020-01-09 | 2020-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-09 | 2020-01-23 | 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 | 2020-01-09 | 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 | 2020-01-09 | 2020-01-23 | 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 | 2020-01-09 | 2020-01-23 | N |
| Provide or obtain dental services for each resident. | Health | 2020-01-09 | 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 | 2020-01-09 | 2020-01-23 | N |
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