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Deficiency Records for Soundview Rehabilitation and Health Care Inc
A list of the most recent deficiencies for Soundview Rehabilitation and Health Care Inc. 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 Soundview Rehabilitation and Health Care Inc. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-29 | 2024-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-29 | 2024-10-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-29 | 2024-10-01 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-08-29 | 2024-10-01 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-21 | 2024-07-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-29 | 2024-07-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-29 | 2024-07-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-29 | 2024-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-29 | 2024-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-29 | 2024-07-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-29 | 2024-07-17 | N |
| 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 | 2024-05-29 | 2024-07-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-29 | 2024-07-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-29 | 2024-07-17 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-05-29 | 2024-07-17 | 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 | 2024-05-29 | 2024-07-17 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-05-21 | 2024-06-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-04-25 | 2024-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-25 | 2024-06-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-25 | 2024-06-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-25 | 2024-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-25 | 2024-06-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-18 | 2024-02-15 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-06-02 | 2023-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-02 | 2023-06-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-02 | 2023-06-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-13 | 2023-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-13 | 2023-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-13 | 2023-04-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-13 | 2023-04-25 | 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 | 2023-03-13 | 2023-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-13 | 2023-04-25 | N |
| Develop a communication plan. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-08 | 2023-04-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-08 | 2023-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-14 | 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 | 2022-12-07 | 2023-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-09-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-18 | 2022-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-18 | 2022-08-31 | 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 | 2022-07-18 | 2022-08-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-07 | 2022-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-08-15 | 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 | 2022-07-07 | 2022-08-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-11 | 2022-04-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-11 | 2022-04-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-11 | 2022-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-28 | 2022-01-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-03 | 2021-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-03 | 2021-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-03 | 2021-12-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-03 | 2021-12-28 | Y |
| 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 | 2021-12-03 | 2021-12-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-03 | 2021-12-28 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-06 | 2019-12-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-06 | 2019-12-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-06 | 2019-12-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-11-06 | 2019-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-12-19 | N |
| 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 | 2019-11-06 | 2019-12-19 | N |
| Post nurse staffing information every day. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-11-06 | 2019-12-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-11-06 | 2019-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-06 | 2019-12-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-06 | 2019-12-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-06 | 2019-12-19 | 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 | 2019-11-06 | 2019-12-19 | N |
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