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Deficiency Records for Squirrel Hill Wellness and Rehabilitation Center
A list of the most recent deficiencies for Squirrel Hill Wellness 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 Squirrel Hill Wellness 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-23 | 2024-05-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-07 | 2024-05-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-07 | 2024-05-17 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-07 | 2024-05-17 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-12 | 2024-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-12 | 2024-04-04 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-12 | 2024-04-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-12 | 2024-04-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-12 | 2024-04-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-02-12 | 2024-04-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-12 | 2024-04-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-12 | 2024-04-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-12 | 2024-04-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-12 | 2024-04-04 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-02-12 | 2024-04-04 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-02-12 | 2024-04-04 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-02-12 | 2024-04-04 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-12 | 2024-04-04 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-02-12 | 2024-04-04 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-02-12 | 2024-04-04 | N |
| Provide training in compliance and ethics. | Health | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-02-12 | 2024-04-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-12 | 2024-04-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-12 | 2024-04-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-12 | 2024-04-04 | 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 | 2024-02-12 | 2024-04-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-12 | 2024-04-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-12 | 2024-04-04 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-12 | 2024-03-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-12 | 2024-03-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-12 | 2024-03-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-15 | 2023-11-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-12 | 2023-11-29 | 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 | 2023-07-20 | 2023-08-30 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-07-20 | 2023-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-08-30 | 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 | 2023-07-20 | 2023-08-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-07-03 | 2023-07-07 | Y |
| 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 | 2023-05-17 | 2023-07-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-17 | 2023-07-03 | Y |
| 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 | 2023-05-17 | 2023-07-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-17 | 2023-07-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-06 | 2023-04-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-06 | 2023-04-19 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-06 | 2023-04-19 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-06 | 2023-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-06 | 2023-04-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-06 | 2023-04-19 | 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 | 2023-03-06 | 2023-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-06 | 2023-04-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-06 | 2023-04-19 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-03-06 | 2023-04-19 | 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 | 2023-03-06 | 2023-04-19 | Y |
| 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 | 2023-03-06 | 2023-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-06 | 2023-04-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-06 | 2023-04-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-06 | 2023-04-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-06 | 2023-04-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-06 | 2023-04-19 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-06 | 2023-04-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Dispose of garbage and refuse properly. | Health | 2023-02-09 | 2023-02-28 | 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 | 2023-01-19 | 2023-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-30 | 2022-12-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-27 | 2022-10-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-27 | 2022-10-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-27 | 2022-10-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-10-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-26 | 2022-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-26 | 2022-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-26 | 2022-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-16 | 2022-05-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-16 | 2022-05-17 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-16 | 2022-05-17 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-03-14 | 2022-04-16 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-03-14 | 2022-04-16 | 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 | 2022-03-14 | 2022-04-16 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-03-14 | 2022-04-16 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-14 | 2022-04-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-01 | 2021-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-01 | 2021-11-23 | Y |
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