Deficiency Records for Shalom Gardens Health and Rehabilitation
Updated as of August 01, 2024
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Deficiency Records for Shalom Gardens Health and Rehabilitation
A list of the most recent deficiencies for Shalom Gardens Health and Rehabilitation. 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 Shalom Gardens Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-14 | 2023-10-18 | 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 | 2021-12-16 | 2022-01-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-16 | 2022-01-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-01-11 | Y |
| 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 | 2021-07-28 | 2021-09-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-28 | 2021-09-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-22 | 2021-09-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-07-22 | 2021-09-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-22 | 2021-09-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-22 | 2021-09-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-22 | 2021-09-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-22 | 2021-09-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-22 | 2021-09-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-22 | 2021-09-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-22 | 2021-09-03 | 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 | 2021-07-22 | 2021-09-03 | 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 | 2021-07-22 | 2021-09-03 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-07-22 | 2021-09-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-21 | 2019-05-22 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-21 | 2019-05-01 | 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 | 2019-03-21 | 2019-05-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-03-21 | 2019-05-01 | 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 | 2019-03-21 | 2019-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-21 | 2019-05-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-14 | 2019-04-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-03-14 | 2019-04-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-14 | 2019-04-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-14 | 2019-04-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-03-14 | 2019-04-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-14 | 2019-04-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-14 | 2019-04-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-14 | 2019-04-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-14 | 2019-04-28 | 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 | 2019-03-14 | 2019-04-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-03-14 | 2019-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-14 | 2019-04-28 | 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 | 2019-03-14 | 2019-04-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-14 | 2019-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-14 | 2019-04-28 | 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 | 2019-03-14 | 2019-04-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-14 | 2019-04-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-03-14 | 2019-04-28 | 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 | 2019-03-14 | 2019-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-14 | 2019-04-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-03-14 | 2019-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-14 | 2019-04-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-14 | 2019-04-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-03-14 | 2019-04-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-03-14 | 2019-04-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-03-14 | 2019-04-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-14 | 2019-04-28 | 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 | 2018-01-19 | 2018-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-19 | 2018-04-20 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-01-19 | 2018-03-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-19 | 2018-03-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-19 | 2018-03-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-19 | 2018-03-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-19 | 2018-03-02 | N |
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