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Deficiency Records for Highland Manor of Fallon Rehabilitation LLC
A list of the most recent deficiencies for Highland Manor of Fallon Rehabilitation LLC. 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 Highland Manor of Fallon Rehabilitation LLC. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-04-30 | 2024-06-26 | 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 | 2024-04-30 | 2024-06-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-30 | 2024-06-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-30 | 2024-06-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-30 | 2024-06-17 | 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 | 2024-04-30 | 2024-06-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-30 | 2024-06-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-11 | 2023-10-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-11 | 2023-10-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-11 | 2023-10-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-09-11 | 2023-10-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-08 | 2023-07-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-08 | 2023-07-28 | 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 | 2023-06-08 | 2023-07-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-08 | 2023-07-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-08 | 2023-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-07-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-08 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-08 | 2023-07-28 | 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 | 2023-06-08 | 2023-07-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-08 | 2023-07-28 | 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 | 2023-06-08 | 2023-07-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-08 | 2023-07-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-06-08 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-07-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-08 | 2023-07-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-08 | 2023-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-07-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-08 | 2023-07-28 | 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 | 2023-06-08 | 2023-07-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-08 | 2023-07-28 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-08 | 2023-07-28 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-08 | 2023-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-07 | 2023-07-28 | 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 | 2023-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-07-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-24 | 2023-05-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-15 | 2022-11-28 | Y |
| 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 | 2022-08-03 | 2022-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-03 | 2022-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-03 | 2022-09-30 | 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 | 2022-08-03 | 2022-09-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-08-03 | 2022-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-09-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-03 | 2022-09-10 | 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 | 2022-08-04 | 2022-09-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-08-04 | 2022-09-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-04 | 2022-09-09 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-08-04 | 2022-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-09-09 | 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 | 2022-08-04 | 2022-09-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-08-04 | 2022-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-09-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-04 | 2022-09-09 | 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 | 2022-08-04 | 2022-09-09 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-04 | 2022-09-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-04 | 2022-09-09 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-08-04 | 2022-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-04 | 2022-09-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-09-09 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-03 | 2022-08-31 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-21 | 2022-01-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-05 | 2021-11-08 | 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 | 2021-10-05 | 2021-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-05 | 2021-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-04 | 2021-11-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-04 | 2021-10-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-04 | 2021-10-29 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-04 | 2021-10-29 | 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 | 2021-10-04 | 2021-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-04 | 2021-10-29 | 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 | 2021-10-04 | 2021-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-04 | 2021-10-29 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-04 | 2021-10-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-04 | 2021-10-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-04 | 2021-10-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-04 | 2021-10-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-04 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-04 | 2021-10-29 | Y |
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