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Deficiency Records for Aegis Health and Rehabilitation
A list of the most recent deficiencies for Aegis 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 Aegis 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-09 | 2024-06-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-21 | 2024-06-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-09 | 2024-06-06 | 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 | 2024-04-09 | 2024-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-09 | 2024-06-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-09 | 2024-06-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-04-09 | 2024-05-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-09 | 2024-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-09 | 2024-05-09 | 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 | 2024-04-09 | 2024-05-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-09 | 2024-05-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-09 | 2024-05-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-04-09 | 2024-05-09 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-04-09 | 2024-05-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-04-09 | 2024-05-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-09 | 2024-05-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-09 | 2024-05-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-09 | 2024-05-09 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-04-09 | 2024-05-09 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-09 | 2024-05-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-11 | 2024-02-29 | 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 | 2023-12-11 | 2024-01-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-11 | 2024-01-29 | Y |
| 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 | 2023-12-11 | 2024-01-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-11 | 2024-01-12 | Y |
| 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 | 2023-12-11 | 2024-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-11 | 2024-01-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-11 | 2024-01-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-11 | 2024-01-12 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-11 | 2024-01-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-11 | 2024-01-12 | 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 | 2023-12-11 | 2024-01-12 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-12-11 | 2024-01-12 | 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 | 2023-12-11 | 2024-01-12 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-12-11 | 2024-01-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-11 | 2024-01-12 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-11 | 2024-01-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-11 | 2024-01-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-07-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-08 | 2023-07-18 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-03-01 | 2023-03-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-05 | 2023-03-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-01 | 2023-02-24 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-05 | 2022-09-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-05 | 2022-09-12 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-08-05 | 2022-09-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-05 | 2022-09-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-05 | 2022-09-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-05 | 2022-09-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-05 | 2022-09-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-05 | 2022-09-12 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-08-05 | 2022-09-12 | Y |
| 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 | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-05 | 2022-09-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-05 | 2022-09-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-05 | 2022-09-12 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-05 | 2022-09-12 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-05 | 2022-09-12 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-05 | 2022-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-05 | 2022-09-12 | 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 | 2022-08-05 | 2022-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-05 | 2022-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-05 | 2022-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-01 | 2019-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-01 | 2019-12-13 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-01 | 2019-12-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-01 | 2019-12-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-01 | 2019-12-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-01 | 2019-12-09 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-01 | 2019-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-01 | 2019-12-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-01 | 2019-12-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-01 | 2019-12-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-01 | 2019-12-09 | N |
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