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Deficiency Records for South Hills Rehabilitation Center
A list of the most recent deficiencies for South Hills 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 South Hills 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? |
|---|---|---|---|---|
| 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 | 2024-03-22 | 2024-06-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-22 | 2024-06-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-22 | 2024-06-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-22 | 2024-05-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-22 | 2024-05-08 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-03-22 | 2024-05-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-03-22 | 2024-05-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-22 | 2024-05-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-22 | 2024-05-08 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-03-22 | 2024-05-08 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-22 | 2024-05-08 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-03-22 | 2024-05-08 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-22 | 2024-05-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-22 | 2024-05-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-22 | 2024-05-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-22 | 2024-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | 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 | 2024-03-22 | 2024-05-08 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-22 | 2024-05-08 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-03-22 | 2024-05-08 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-03-22 | 2024-05-08 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-03-22 | 2024-05-08 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-27 | 2024-05-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-27 | 2024-05-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-27 | 2024-05-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-28 | 2023-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-03-07 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-27 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-11-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-11 | 2022-03-31 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-01-11 | 2022-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-11 | 2022-02-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-11 | 2022-02-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-11 | 2022-02-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-11 | 2022-02-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-11 | 2022-02-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-11 | 2022-02-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-11 | 2022-02-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-11 | 2022-02-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-11 | 2022-02-25 | Y |
| 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 | 2022-01-11 | 2022-02-25 | 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 | 2022-01-11 | 2022-02-25 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-11 | 2022-02-25 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-01-11 | 2022-02-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-05 | 2019-05-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-05 | 2019-05-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-05 | 2019-05-21 | 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 | 2019-04-05 | 2019-05-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-05 | 2019-05-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-05 | 2019-05-21 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-05 | 2019-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-05 | 2019-05-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-02 | 2019-05-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-02 | 2019-05-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-02 | 2019-05-21 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-02 | 2019-05-21 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-11-03 | 2017-12-20 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-11-03 | 2017-12-20 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-03 | 2017-12-20 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-03 | 2017-12-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-03 | 2017-12-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-03 | 2017-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-02 | 2017-12-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-11-02 | 2017-12-11 | N |
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