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Deficiency Records for Ormsby Post Acute Rehabilitation
A list of the most recent deficiencies for Ormsby Post Acute 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 Ormsby Post Acute 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-29 | 2024-07-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-29 | 2024-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-29 | 2024-07-24 | N |
| 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 | 2024-05-29 | 2024-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-29 | 2024-07-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-29 | 2024-07-24 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2024-05-29 | 2024-07-24 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-05-29 | 2024-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-29 | 2024-07-24 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-05-29 | 2024-07-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-29 | 2024-07-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-29 | 2024-07-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-29 | 2024-07-24 | 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 | 2024-05-29 | 2024-07-24 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-05-29 | 2024-07-24 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-05-29 | 2024-07-24 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-05-29 | 2024-07-24 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-29 | 2024-07-24 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide training in compliance and ethics. | Health | 2024-05-29 | 2024-07-24 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-05-29 | 2024-07-24 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-29 | 2024-07-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-29 | 2024-07-24 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-29 | 2024-07-18 | 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 | 2024-05-29 | 2024-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2024-05-29 | 2024-07-18 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-05-29 | 2024-05-29 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-16 | 2024-03-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-16 | 2024-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-16 | 2024-03-11 | 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 | 2024-02-16 | 2024-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-16 | 2024-03-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-16 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-05 | 2023-09-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-05 | 2023-08-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-05 | 2023-08-15 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-05 | 2023-08-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-05 | 2023-08-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-07-05 | 2023-08-15 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-07-05 | 2023-08-15 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-07-05 | 2023-08-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-07-05 | 2023-08-15 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-05 | 2023-08-15 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-07-05 | 2023-08-15 | N |
| Provide training in compliance and ethics. | Health | 2023-07-05 | 2023-08-15 | 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 | 2023-07-05 | 2023-08-15 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-05 | 2023-08-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-05 | 2023-07-29 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-05 | 2023-07-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-05 | 2023-07-29 | 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 | 2023-07-05 | 2023-07-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-05 | 2023-07-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-05 | 2023-07-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-05 | 2023-07-29 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-05 | 2023-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-05 | 2023-07-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Develop a communication plan. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Establish methods for sharing information. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-28 | 2023-07-29 | 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 | 2023-06-28 | 2023-07-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-06-28 | 2023-07-29 | 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 | 2023-06-28 | 2023-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-27 | 2023-06-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-01 | 2023-03-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-01 | 2023-03-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-01 | 2023-03-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-01 | 2023-03-31 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-03-01 | 2023-03-31 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-18 | 2022-10-04 | 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 | 2022-08-18 | 2022-10-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-18 | 2022-10-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-18 | 2022-10-02 | 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 | 2022-08-18 | 2022-10-02 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-08-18 | 2022-10-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-18 | 2022-10-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-18 | 2022-10-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-18 | 2022-10-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-18 | 2022-10-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-10-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-10-02 | 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 | 2022-08-18 | 2022-10-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-18 | 2022-10-02 | 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 | 2022-08-18 | 2022-10-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-18 | 2022-10-02 | 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 | 2022-08-18 | 2022-10-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-18 | 2022-10-02 | 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 | 2022-08-18 | 2022-10-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-18 | 2022-10-02 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-08-18 | 2022-10-02 | N |
| Report COVID19 data to residents and families. | Health | 2022-07-21 | 2022-08-05 | 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 | 2022-07-21 | 2022-08-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-01 | 2022-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-01 | 2022-07-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-01 | 2022-07-01 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-01 | 2022-07-01 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-01 | 2022-07-01 | Y |
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