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Deficiency Records for New Vanderbilt Rehabilitation and Care Center, Inc
A list of the most recent deficiencies for New Vanderbilt Rehabilitation and Care Center, Inc. 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 New Vanderbilt Rehabilitation and Care Center, Inc. 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 | 2024-07-16 | 2024-09-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-16 | 2024-09-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-16 | 2024-09-13 | 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 | 2024-07-16 | 2024-09-13 | Y |
| 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 | 2024-07-16 | 2024-09-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-16 | 2024-09-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-16 | 2024-09-13 | 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 | 2024-07-16 | 2024-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-16 | 2024-09-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-07-16 | 2024-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-16 | 2024-09-13 | 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 | 2024-07-16 | 2024-09-13 | 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 | 2024-07-16 | 2024-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-16 | 2024-09-13 | N |
| Dispose of garbage and refuse properly. | Health | 2024-07-16 | 2024-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-16 | 2024-09-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-07-16 | 2024-09-13 | 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 | 2024-07-16 | 2024-09-13 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-07-16 | 2024-09-13 | 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 | 2024-07-16 | 2024-09-13 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-07-16 | 2024-09-13 | Y |
| Use approved construction type or materials. | Fire Safety | 2024-07-16 | 2024-09-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-07-16 | 2024-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-16 | 2024-09-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-07-16 | 2024-09-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-09 | 2024-01-03 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-09 | 2024-01-03 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-11-09 | 2024-01-03 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-26 | 2023-08-20 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-05-26 | 2023-08-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-26 | 2023-08-08 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-05-26 | 2023-08-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-26 | 2023-08-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-26 | 2023-08-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-26 | 2023-08-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-26 | 2023-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-26 | 2023-08-01 | 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 | 2023-05-26 | 2023-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-26 | 2023-08-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-26 | 2023-08-01 | 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 | 2023-05-26 | 2023-08-01 | 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 | 2023-05-26 | 2023-08-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-26 | 2023-08-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-26 | 2023-08-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-26 | 2023-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-26 | 2023-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-26 | 2023-08-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-26 | 2023-07-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-26 | 2023-07-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-26 | 2023-07-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-26 | 2023-07-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-26 | 2023-07-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-26 | 2023-06-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-26 | 2023-06-16 | 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 | 2023-05-26 | 2023-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-26 | 2023-06-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-23 | 2022-04-27 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-10-20 | 2020-11-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-10-20 | 2020-11-16 | 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 | 2020-10-20 | 2020-11-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-10-20 | 2020-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-20 | 2020-11-16 | N |
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