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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 |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-10-29 | Y |
| 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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