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Deficiency Records for Fernhill Rehabilitation and Care

A list of the most recent deficiencies for Fernhill Rehabilitation and Care. 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 Fernhill Rehabilitation and Care. 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-03-22 2024-05-08 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-03-22 2024-05-08 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-03-22 2024-05-08 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2024-03-22 2024-05-08 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-03-22 2024-05-08 N
Keep residents' personal and medical records private and confidential. Health 2024-03-22 2024-05-08 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 2024-03-22 2024-05-08 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2024-03-22 2024-05-08 N
Ensure each resident receives an accurate assessment. Health 2024-03-22 2024-05-08 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2024-03-22 2024-05-08 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-03-22 2024-05-08 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 2024-03-22 2024-05-08 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-03-22 2024-05-08 N
Provide activities to meet all resident's needs. Health 2024-03-22 2024-05-08 N
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 2024-03-22 2024-05-08 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-22 2024-05-08 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2024-03-22 2024-05-08 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-03-22 2024-05-08 N
Ensure medication error rates are not 5 percent or greater. Health 2024-03-22 2024-05-08 N
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2024-03-22 2024-05-08 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-03-22 2024-05-08 N
Provide and implement an infection prevention and control program. Health 2024-03-22 2024-05-08 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-03-22 2024-05-08 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-22 2024-05-08 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-03-22 2024-05-08 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-03-27 2024-05-08 N
Install an approved automatic sprinkler system. Fire Safety 2024-03-27 2024-05-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-03-27 2024-05-08 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-03-27 2024-05-08 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-06-01 2023-06-20 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-03-16 2023-04-26 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-03-16 2023-04-26 Y
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2022-12-15 2023-02-07 N
Provide properly protected cooking facilities. Fire Safety 2022-12-15 2023-02-07 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-12-15 2023-02-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-15 2023-02-07 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-12-15 2023-02-07 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2022-12-20 2023-01-09 N
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2022-12-20 2023-01-09 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2022-12-20 2023-01-09 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-12-20 2023-01-09 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 2022-12-20 2023-01-09 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2022-12-20 2023-01-09 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-12-20 2023-01-09 N
Provide activities to meet all resident's needs. Health 2022-12-20 2023-01-09 N
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 2022-12-20 2023-01-09 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 2022-12-20 2023-01-09 N
Ensure medication error rates are not 5 percent or greater. Health 2022-12-20 2023-01-09 N
Provide or get specialized rehabilitative services as required for a resident. Health 2022-12-20 2023-01-09 N
Provide and implement an infection prevention and control program. Health 2022-12-20 2023-01-09 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-12-20 2023-01-09 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-12-20 2023-01-09 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-12-20 2023-01-09 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-09-27 2019-11-20 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 2019-09-27 2019-11-15 N
Provide properly protected cooking facilities. Fire Safety 2019-09-27 2019-11-15 N
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2019-09-27 2019-11-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-09-27 2019-11-15 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-10-01 2019-11-08 N
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 2019-10-01 2019-11-08 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 2019-10-01 2019-11-08 N
Provide and implement an infection prevention and control program. Health 2019-10-01 2019-11-08 N

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