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Deficiency Records for Douglas Cove Health and Rehabilitation
A list of the most recent deficiencies for Douglas Cove Health and Rehabilitation. 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 Douglas Cove Health and Rehabilitation. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-18 | 2024-08-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-18 | 2024-08-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-18 | 2024-08-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-18 | 2024-08-21 | 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 | 2024-07-18 | 2024-08-21 | 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 | 2024-07-18 | 2024-08-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-18 | 2024-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-18 | 2024-08-21 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-07-18 | 2024-08-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-18 | 2024-08-21 | Y |
| 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 | 2024-07-18 | 2024-08-21 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-07-17 | 2024-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-17 | 2024-08-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-17 | 2024-08-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-17 | 2024-08-21 | 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 | 2023-06-07 | 2023-07-14 | 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 | 2023-06-07 | 2023-07-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-07-14 | 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 | 2023-06-07 | 2023-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-07 | 2023-07-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-07 | 2023-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2022-12-22 | 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 | 2022-03-10 | 2022-05-13 | 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 | 2022-03-10 | 2022-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-04-14 | 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 | 2022-03-10 | 2022-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-10 | 2022-04-12 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-03-10 | 2022-04-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-10 | 2022-04-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-10 | 2022-04-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-10 | 2022-04-12 | 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 | 2022-03-10 | 2022-04-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-10 | 2022-04-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-10 | 2022-04-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-10 | 2022-04-12 | 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 | 2022-03-10 | 2022-04-12 | 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 | 2022-03-10 | 2022-04-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-10 | 2022-04-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-10 | 2022-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-10 | 2022-04-12 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-10 | 2022-04-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-10 | 2022-04-11 | N |
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