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Deficiency Records for Faith Community Nursing and Rehabilitation

A list of the most recent deficiencies for Faith Community Nursing and Rehabilitation. 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 Faith Community Nursing and Rehabilitation. 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?
Assess the resident when there is a significant change in condition Health 2023-08-26 2023-08-27 N
Ensure each resident receives an accurate assessment. Health 2023-08-26 2023-08-27 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-08-26 2023-08-27 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-08-26 2023-08-27 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 2023-08-26 2023-08-27 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-08-26 2023-08-27 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-26 2023-08-27 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-08-26 2023-08-27 Y
Implement emergency and standby power systems. Fire Safety 2023-08-24 2023-08-25 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-08-24 2023-08-25 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-08-24 2023-08-25 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-08-24 2023-08-25 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2023-08-24 2023-08-25 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-03-08 2023-03-17 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-09-21 2022-10-12 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-08-02 2022-08-26 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2022-08-02 2022-08-26 N
Establish roles under a Waiver declared by secretary. Fire Safety 2022-08-02 2022-08-26 N
List the names and contact information of those in the facility. Fire Safety 2022-08-02 2022-08-26 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-08-02 2022-08-16 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2022-08-02 2022-08-10 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-08-02 2022-08-03 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-08-02 2022-08-03 N
Have restrictions on the use of portable space heaters. Fire Safety 2022-08-02 2022-08-03 N
Have proper medical gas storage and administration areas. Fire Safety 2022-08-02 2022-08-03 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-07-14 2022-07-25 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2022-07-14 2022-07-15 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-07-14 2022-07-15 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-07-14 2022-07-15 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-07-14 2022-07-15 N
Post nurse staffing information every day. Health 2022-07-14 2022-07-15 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2022-07-14 2022-07-15 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-07-14 2022-07-15 N
Keep all essential equipment working safely. Health 2022-07-14 2022-07-15 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-05-21 2021-08-20 N
Address subsistence needs for staff and patients. Fire Safety 2021-05-21 2021-07-07 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2021-05-21 2021-07-07 N
Establish policies and procedures for volunteers. Fire Safety 2021-05-21 2021-07-07 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2021-05-21 2021-06-17 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-05-21 2021-06-17 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2021-05-21 2021-06-11 N
Establish policies and procedures for sheltering. Fire Safety 2021-05-21 2021-06-11 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-05-21 2021-06-11 N
Establish roles under a Waiver declared by secretary. Fire Safety 2021-05-21 2021-06-11 N
Establish methods for sharing information. Fire Safety 2021-05-21 2021-06-11 N
Establish emergency prep training and testing. Fire Safety 2021-05-21 2021-06-11 N
Establish staff and initial training requirements. Fire Safety 2021-05-21 2021-06-11 N
Conduct testing and exercise requirements. Fire Safety 2021-05-21 2021-06-11 N
Implement emergency and standby power systems. Fire Safety 2021-05-21 2021-06-11 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2021-05-21 2021-06-08 N
Establish policies and procedures for medical documentation. Fire Safety 2021-05-21 2021-05-21 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-05-21 2021-05-21 N
Have an alternate power supply for its alarm system. Fire Safety 2021-05-21 2021-05-21 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-05-21 2021-05-21 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-05-21 2021-05-21 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-05-21 2021-05-21 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2021-05-21 2021-05-21 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-05-21 2021-05-21 N

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