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Deficiency Records for Nashville Center For Rehabilitation and Healing Ll
A list of the most recent deficiencies for Nashville Center For Rehabilitation and Healing Ll. 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 Nashville Center For Rehabilitation and Healing Ll. 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? |
|---|---|---|---|---|
| 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 | 2023-03-13 | 2023-05-13 | N |
| Provide large enough exits. | Fire Safety | 2023-03-13 | 2023-05-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-03-13 | 2023-05-13 | 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 | 2023-03-13 | 2023-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-13 | 2023-05-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-03-16 | 2023-04-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-16 | 2023-04-21 | 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 | 2023-03-16 | 2023-04-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-16 | 2023-04-21 | 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 | 2023-03-16 | 2023-04-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-03-16 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-16 | 2023-04-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-16 | 2023-04-21 | 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 | 2023-03-16 | 2023-04-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-16 | 2023-04-21 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-03-16 | 2023-04-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-13 | 2023-04-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-01 | 2022-11-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-01 | 2022-11-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-20 | 2021-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-20 | 2021-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-20 | 2021-11-19 | 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 | 2021-10-20 | 2021-11-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-20 | 2021-11-19 | Y |
| Post nurse staffing information every day. | Health | 2021-10-20 | 2021-11-19 | 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 | 2019-04-24 | 2019-06-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-24 | 2019-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-24 | 2019-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-22 | 2019-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-22 | 2019-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-22 | 2019-05-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-22 | 2019-05-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-22 | 2019-05-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-22 | 2019-05-17 | 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 | 2018-04-11 | 2018-05-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-11 | 2018-05-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-11 | 2018-05-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-11 | 2018-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-11 | 2018-05-01 | 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 | 2018-04-11 | 2018-05-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-11 | 2018-05-01 | 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 | 2018-04-11 | 2018-05-01 | 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 | 2018-04-11 | 2018-05-01 | 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 | 2018-04-11 | 2018-05-01 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-04-11 | 2018-05-01 | N |
| 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 | 2018-04-11 | 2018-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-11 | 2018-05-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-11 | 2018-05-01 | N |
| Keep all essential equipment working safely. | Health | 2018-04-11 | 2018-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-09 | 2018-05-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-04-09 | 2018-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-09 | 2018-04-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-09 | 2018-04-09 | N |
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