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Deficiency Records for Divine Rehabilitation and Nursing at Shane Hill
A list of the most recent deficiencies for Divine Rehabilitation and Nursing at Shane Hill. 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 Divine Rehabilitation and Nursing at Shane Hill. 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? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-04-10 | 2024-05-17 | Y |
| 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 | 2024-04-10 | 2024-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-10 | 2024-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-10 | 2024-05-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-10 | 2024-05-17 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-10 | 2024-05-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-10 | 2024-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-10 | 2024-05-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-02 | 2024-05-17 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-11 | 2024-05-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-11 | 2024-05-17 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-11 | 2024-04-02 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-27 | 2023-06-30 | 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 | 2023-04-27 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-06-30 | 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 | 2023-04-27 | 2023-06-30 | N |
| 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 | 2023-04-27 | 2023-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-27 | 2023-06-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-28 | 2022-12-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-18 | 2022-02-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-18 | 2022-02-18 | Y |
| 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 | 2020-02-20 | 2020-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | N |
| Provide or obtain dental services for each resident. | Health | 2020-02-20 | 2020-03-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-20 | 2020-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-03-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-19 | 2020-03-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-19 | 2020-03-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-19 | 2020-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-03-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-19 | 2020-03-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-19 | 2020-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-19 | 2020-03-31 | N |
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