Deficiency Records for Shandin Hills Behavior Therapy Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Shandin Hills Behavior Therapy 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-03 | 2023-11-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-03 | 2023-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2023-11-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-03 | 2023-11-29 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-08-30 | 2023-09-14 | 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 | 2023-08-28 | 2023-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-05-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-15 | 2023-03-03 | 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 | 2022-11-18 | 2022-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-18 | 2022-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2022-12-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-11-18 | 2022-12-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-18 | 2022-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Use approved construction type or materials. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-30 | 2022-12-13 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-11-03 | 2022-12-05 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-24 | 2019-10-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-24 | 2019-10-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-24 | 2019-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-06 | 2019-10-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-06 | 2019-10-03 | 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 | 2019-09-06 | 2019-10-03 | 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 | 2019-09-06 | 2019-10-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-09-06 | 2019-10-03 | 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 | 2019-09-06 | 2019-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-06 | 2019-10-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-06 | 2019-10-03 | N |
