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Deficiency Records for Hall of Fame Rehabilitation and Nursing Center
A list of the most recent deficiencies for Hall of Fame Rehabilitation and Nursing 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 Hall of Fame Rehabilitation and Nursing 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-08-19 | 2024-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-19 | 2024-09-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-08-19 | 2024-09-16 | 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 | 2024-08-19 | 2024-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-19 | 2024-09-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-19 | 2024-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-19 | 2024-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-15 | 2024-09-16 | N |
| Keep all essential equipment working safely. | Health | 2024-02-28 | 2024-04-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-28 | 2024-04-17 | Y |
| Meet other general requirements. | Fire Safety | 2024-02-26 | 2024-04-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-28 | 2024-04-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-04-16 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-26 | 2024-03-29 | Y |
| 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 | 2023-08-11 | 2023-08-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-21 | 2023-08-04 | Y |
| 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 | 2023-05-01 | 2023-06-16 | 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 | 2023-05-01 | 2023-06-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-01 | 2023-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-01 | 2023-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-01 | 2023-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-01 | 2023-06-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-01 | 2023-06-05 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-05-01 | 2023-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-01 | 2023-06-05 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-01 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | 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 | 2023-04-25 | 2023-06-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-17 | 2022-07-15 | 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 | 2022-06-17 | 2022-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-17 | 2022-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-07-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-17 | 2021-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-17 | 2021-12-14 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-17 | 2021-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-17 | 2021-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-10-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-06-30 | 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 | 2021-05-13 | 2021-06-30 | 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 | 2021-05-13 | 2021-06-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-13 | 2021-06-30 | 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 | 2021-05-18 | 2021-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-18 | 2021-06-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-18 | 2021-06-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-18 | 2021-06-11 | N |
| Develop a communication plan. | Fire Safety | 2021-05-18 | 2021-06-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-18 | 2021-06-11 | N |
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