Deficiency Records for Seven Hills Rehabilitation and Nursing
Updated as of August 01, 2024
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Deficiency Records for Seven Hills Rehabilitation and Nursing
A list of the most recent deficiencies for Seven Hills Rehabilitation and Nursing. 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 Seven Hills Rehabilitation and Nursing. 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? |
---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-27 | 2023-10-31 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-27 | 2023-10-31 | Y |
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2023-09-27 | 2023-10-31 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-27 | 2023-10-31 | Y |
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 | 2023-09-27 | 2023-10-31 | Y |
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2023-08-02 | 2023-10-31 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-02 | 2023-10-31 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-02 | 2023-10-31 | 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 | 2023-08-02 | 2023-10-31 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-02 | 2023-10-31 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-25 | 2023-09-21 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-02 | 2023-09-12 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-02 | 2023-09-12 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-02 | 2023-09-12 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-02 | 2023-09-12 | 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 | 2023-08-02 | 2023-09-12 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-02 | 2023-09-12 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-08-02 | 2023-09-12 | 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 | 2023-08-02 | 2023-09-12 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-02 | 2023-09-12 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-02 | 2023-09-12 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-02 | 2023-09-12 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-02 | 2023-09-12 | 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 | 2023-08-02 | 2023-09-12 | 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 | 2023-08-02 | 2023-09-12 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-02 | 2023-09-12 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-09-12 | N |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-02 | 2023-09-12 | N |
Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-09-12 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-02 | 2023-09-12 | N |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-02 | 2023-09-12 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-09-12 | Y |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-02 | 2023-09-12 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-02 | 2023-09-12 | Y |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Meet other general requirements that are deficient. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Provide properly protected cooking facilities. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Meet other general requirements that are deficient. | Fire Safety | 2023-08-01 | 2023-08-23 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-01 | 2023-08-23 | 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 | 2023-05-16 | 2023-06-29 | 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 | 2023-05-16 | 2023-06-29 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-16 | 2023-06-29 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-16 | 2023-06-29 | Y |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-05-16 | 2023-06-29 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-16 | 2023-06-29 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-16 | 2023-06-29 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-02 | 2023-06-22 | Y |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-02 | 2023-06-09 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-24 | 2023-05-11 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-24 | 2023-05-11 | Y |
Respond appropriately to all alleged violations. | Health | 2023-03-24 | 2023-05-11 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-24 | 2023-05-11 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-13 | 2023-02-14 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-02-14 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-14 | 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 | 2023-01-13 | 2023-02-14 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-13 | 2023-02-14 | Y |
Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-12-01 | 2022-01-04 | N |
Ensure each resident receives an accurate assessment. | Health | 2021-12-01 | 2022-01-04 | 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 | 2021-12-01 | 2022-01-04 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-01 | 2022-01-04 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-01 | 2022-01-04 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-01 | 2022-01-04 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-01 | 2022-01-04 | 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 | 2021-12-01 | 2022-01-04 | N |
Provide and implement an infection prevention and control program. | Health | 2021-12-01 | 2022-01-04 | N |
Perform COVID19 testing on residents and staff. | Health | 2021-12-01 | 2022-01-04 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-01 | 2022-01-04 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-01 | 2022-01-04 | Y |
Respond appropriately to all alleged violations. | Health | 2021-12-01 | 2022-01-04 | Y |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-07 | 2021-12-13 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-07 | 2021-12-13 | N |
Meet other general requirements. | Fire Safety | 2019-03-13 | 2019-05-07 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-13 | 2019-05-07 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-13 | 2019-05-07 | 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 | 2019-02-26 | 2019-04-08 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-26 | 2019-04-08 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-26 | 2019-04-08 | 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 | 2019-02-26 | 2019-04-08 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-26 | 2019-04-08 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-26 | 2019-04-08 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-26 | 2019-04-08 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-02-26 | 2019-04-08 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-26 | 2019-04-08 | 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 | 2019-02-26 | 2019-04-08 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-26 | 2019-04-08 | 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 | 2019-02-26 | 2019-04-08 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-26 | 2019-04-08 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-02-26 | 2019-04-08 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-26 | 2018-09-26 | N |
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