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Deficiency Records for Estates Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Estates Healthcare and Rehabilitation Center. 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 Estates Healthcare and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-05 | 2024-06-06 | 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 | 2024-06-05 | 2024-06-06 | Y |
| 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 | 2024-01-04 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-30 | 2024-01-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-04 | 2024-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-05 | 2024-01-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-05 | 2024-01-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-05 | 2024-01-08 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-05 | 2024-01-08 | 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 | 2024-01-05 | 2024-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-05 | 2024-01-08 | N |
| Keep all essential equipment working safely. | Health | 2024-01-05 | 2024-01-08 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-01-04 | 2024-01-05 | 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 | 2024-01-04 | 2024-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-04 | 2024-01-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-13 | 2023-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-12 | 2023-10-13 | Y |
| 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 | 2023-04-28 | 2023-05-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-14 | 2023-02-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-04 | 2022-12-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-04 | 2022-12-16 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-04 | 2022-12-16 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-14 | 2022-12-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-04 | 2022-10-05 | Y |
| 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 | 2022-08-10 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-22 | 2022-07-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-22 | 2022-07-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-22 | 2022-07-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-22 | 2022-04-19 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-22 | 2022-04-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-22 | 2022-04-19 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-12-02 | 2021-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-17 | 2021-12-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-17 | 2021-12-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-16 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-12-02 | 2021-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-29 | 2021-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-29 | 2021-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-29 | 2021-11-01 | N |
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