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Deficiency Records for The Grove at North Huntingdon
A list of the most recent deficiencies for The Grove at North Huntingdon. 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 The Grove at North Huntingdon. 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? |
|---|---|---|---|---|
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-02 | 2024-08-22 | 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 | 2024-08-02 | 2024-08-22 | 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 | 2024-08-02 | 2024-08-22 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-08-02 | 2024-08-22 | 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 | 2024-03-05 | 2024-04-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-05 | 2024-04-02 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-20 | 2024-02-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-20 | 2024-02-26 | 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 | 2023-12-20 | 2024-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-20 | 2024-02-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-20 | 2024-02-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-27 | 2024-01-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-21 | 2024-01-30 | N |
| 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 | 2023-12-21 | 2024-01-30 | 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 | 2023-12-21 | 2024-01-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-21 | 2024-01-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-21 | 2024-01-30 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-12-21 | 2024-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-21 | 2024-01-30 | 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 | 2023-12-21 | 2024-01-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-12-21 | 2024-01-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-21 | 2024-01-30 | 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 | 2023-12-21 | 2024-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-01-30 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-12-21 | 2024-01-30 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-12-21 | 2024-01-30 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-12-21 | 2024-01-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-21 | 2024-01-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-21 | 2024-01-30 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-11-29 | 2023-12-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-29 | 2023-12-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-23 | 2023-09-05 | Y |
| Keep all essential equipment working safely. | Health | 2023-08-23 | 2023-09-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-25 | 2023-08-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-25 | 2023-08-22 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-07-25 | 2023-08-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-07-25 | 2023-08-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-25 | 2023-08-22 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-25 | 2023-08-22 | 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 | 2023-07-11 | 2023-07-27 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-07-11 | 2023-07-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-01 | 2023-05-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-01 | 2023-05-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-01 | 2023-05-31 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-27 | 2023-03-02 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-01-27 | 2023-03-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-27 | 2023-03-02 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-27 | 2023-03-02 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2023-01-27 | 2023-03-02 | 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 | 2023-01-27 | 2023-03-02 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-27 | 2023-03-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-27 | 2023-03-02 | 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 | 2023-01-27 | 2023-03-02 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-01-27 | 2023-03-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-27 | 2023-03-02 | 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 | 2023-01-27 | 2023-03-02 | 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 | 2023-01-27 | 2023-03-02 | N |
| 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 | 2023-01-27 | 2023-03-02 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-27 | 2023-03-02 | 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 | 2023-01-27 | 2023-03-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-27 | 2023-03-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-27 | 2023-03-02 | 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 | 2023-01-27 | 2023-03-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-27 | 2023-03-02 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-26 | 2023-02-23 | 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 | 2023-01-26 | 2023-02-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-26 | 2023-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-19 | 2022-12-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-19 | 2022-12-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-22 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-19 | 2022-10-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-23 | 2022-09-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-09 | 2022-09-15 | 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 | 2022-08-09 | 2022-09-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-09 | 2022-09-15 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-08-09 | 2022-09-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-09 | 2022-09-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-09 | 2022-09-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-09 | 2022-09-15 | Y |
| 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 | 2022-08-09 | 2022-09-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-09 | 2022-09-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-03 | 2022-06-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-18 | 2022-05-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-30 | 2022-04-22 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-23 | 2022-03-10 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-30 | 2021-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-30 | 2021-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-30 | 2021-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-26 | 2021-09-24 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-08-26 | 2021-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-26 | 2021-09-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-26 | 2021-09-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-26 | 2021-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-26 | 2021-09-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-26 | 2021-09-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-26 | 2021-09-24 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-08-26 | 2021-09-24 | 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 | 2021-08-26 | 2021-09-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-26 | 2021-09-24 | 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 | 2021-08-26 | 2021-09-24 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-08-26 | 2021-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-26 | 2021-09-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-26 | 2021-09-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-26 | 2021-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-26 | 2021-09-24 | 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 | 2023-06-15 | Not Fixed | Y |
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