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Deficiency Records for Harmar Village Health and Rehab Center
A list of the most recent deficiencies for Harmar Village Health and Rehab 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 Harmar Village Health and Rehab 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-09-25 | 2024-10-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-25 | 2024-10-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-09-25 | 2024-10-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-25 | 2024-10-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-13 | 2024-10-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-13 | 2024-10-03 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-09-13 | 2024-10-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-01 | 2024-08-19 | Y |
| Post nurse staffing information every day. | Health | 2024-08-01 | 2024-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-12 | 2024-06-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-20 | 2024-05-28 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-04-19 | 2024-05-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-19 | 2024-05-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-19 | 2024-05-17 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2024-04-19 | 2024-05-17 | N |
| 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 | 2024-04-19 | 2024-05-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-04-19 | 2024-05-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-19 | 2024-05-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-19 | 2024-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-19 | 2024-05-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-19 | 2024-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-04-19 | 2024-05-17 | 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 | 2024-04-19 | 2024-05-17 | 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 | 2024-04-19 | 2024-05-17 | 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 | 2024-04-19 | 2024-05-17 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-04-19 | 2024-05-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-19 | 2024-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-19 | 2024-05-17 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-04-19 | 2024-05-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-19 | 2024-05-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-19 | 2024-05-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-04-19 | 2024-05-17 | Y |
| 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 | 2024-04-17 | 2024-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-17 | 2024-05-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-12 | 2024-01-09 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-09-19 | 2023-10-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-03 | 2023-09-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-03 | 2023-09-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-03 | 2023-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-03 | 2023-09-06 | Y |
| 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 | 2023-08-03 | 2023-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-03 | 2023-09-06 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-06-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-01 | 2023-06-13 | 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 | 2023-05-01 | 2023-06-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-01 | 2023-06-13 | N |
| Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist. | Health | 2023-05-01 | 2023-06-13 | 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 | 2023-05-01 | 2023-06-13 | 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 | 2023-05-01 | 2023-06-13 | 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 | 2023-06-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-01 | 2023-06-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-01 | 2023-06-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-01 | 2023-06-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-01 | 2023-06-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-01 | 2023-06-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-01 | 2023-06-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-01 | 2023-06-13 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-05-01 | 2023-06-13 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-01 | 2023-06-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-21 | 2023-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-03-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-02 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-04 | 2022-06-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-04 | 2022-06-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-04 | 2022-06-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-04 | 2022-06-07 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-04 | 2022-06-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-04 | 2022-06-07 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-05-04 | 2022-06-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-04 | 2022-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-06-07 | 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 | 2022-05-10 | 2022-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-10 | 2022-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-10 | 2022-06-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-10 | 2022-02-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-04 | 2021-12-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2021-12-07 | Y |
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