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Deficiency Records for Rest Haven Health Care Center
A list of the most recent deficiencies for Rest Haven Health Care 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 Rest Haven Health Care 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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-25 | 2024-05-30 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2024-04-25 | 2024-05-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-25 | 2024-05-30 | N |
| 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 | 2024-04-25 | 2024-05-30 | N |
| Post nurse staffing information every day. | Health | 2024-04-25 | 2024-05-30 | 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 | 2024-04-25 | 2024-05-30 | N |
| 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 | 2024-04-25 | 2024-05-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-25 | 2024-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-25 | 2024-05-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-25 | 2024-05-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-25 | 2024-05-30 | 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 | 2024-04-25 | 2024-05-30 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-04-25 | 2024-05-30 | 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 | 2024-04-25 | 2024-05-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-25 | 2024-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-07-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-09 | 2023-01-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-09 | 2023-01-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-09 | 2023-01-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-09 | 2023-01-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Meet other general requirements. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-12-09 | 2023-01-20 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-28 | 2020-03-12 | 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 | 2020-01-28 | 2020-03-12 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-28 | 2020-03-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-28 | 2020-03-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-01-28 | 2020-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-28 | 2020-03-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-28 | 2020-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-28 | 2020-03-12 | N |
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