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Deficiency Records for Shadyside Skilled Nursing and Rehabilitation Ctr
A list of the most recent deficiencies for Shadyside Skilled Nursing and Rehabilitation Ctr. 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 Shadyside Skilled Nursing and Rehabilitation Ctr. 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 | 2024-07-26 | 2024-09-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-26 | 2024-09-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-26 | 2024-09-09 | 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 | 2024-07-26 | 2024-09-09 | N |
| Respond appropriately to all alleged violations. | Health | 2024-07-26 | 2024-09-09 | N |
| 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 | 2024-07-26 | 2024-09-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-26 | 2024-09-09 | 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 | 2024-07-26 | 2024-09-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-26 | 2024-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-26 | 2024-09-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-26 | 2024-09-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-07-26 | 2024-09-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-26 | 2024-09-09 | 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 | 2024-07-26 | 2024-09-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-26 | 2024-09-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-07-26 | 2024-09-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-26 | 2024-09-09 | 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 | 2024-07-26 | 2024-09-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-26 | 2024-09-09 | 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 | 2024-07-26 | 2024-09-09 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-07-26 | 2024-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-26 | 2024-09-09 | N |
| 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 | 2024-07-26 | 2024-09-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-07-26 | 2024-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-26 | 2024-09-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-26 | 2024-09-09 | N |
| 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 | 2024-07-26 | 2024-09-09 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-07-26 | 2024-09-09 | 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 | 2024-07-26 | 2024-09-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-26 | 2024-09-09 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-07-26 | 2024-09-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-29 | 2024-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-29 | 2024-08-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-29 | 2024-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-29 | 2024-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-27 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-02 | 2023-10-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-11 | 2023-09-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-11 | 2023-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-08-11 | 2023-09-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-11 | 2023-09-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-08-11 | 2023-09-25 | 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 | 2023-07-25 | 2023-09-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-02 | 2022-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-02 | 2022-09-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-02 | 2022-09-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-02 | 2022-09-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-02 | 2022-09-21 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-09-02 | 2022-09-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-09-02 | 2022-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-09-21 | 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 | 2022-09-02 | 2022-09-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-02 | 2022-09-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-06 | 2022-09-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-06 | 2022-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-01 | 2022-09-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-22 | 2022-07-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-22 | 2022-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-22 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-05 | Not Fixed | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-07-05 | Not Fixed | 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 | 2024-07-05 | Not Fixed | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-05 | Not Fixed | Y |
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