A list of the most recent deficiencies for Shady Nook Care 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 | 2023-10-11 | 2023-11-02 | 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 | 2023-10-11 | 2023-11-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-11 | 2023-11-02 | 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 | 2023-10-11 | 2023-11-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-11 | 2023-11-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-25 | 2023-10-16 | Y |
| 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 | 2023-09-25 | 2023-10-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-25 | 2023-10-16 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-25 | 2023-10-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-25 | 2023-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-10-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-11 | 2023-06-09 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Meet other general requirements. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-14 | 2022-10-03 | 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 | 2022-09-14 | 2022-10-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-14 | 2022-10-03 | 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 | 2022-09-14 | 2022-10-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-14 | 2022-10-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-04 | 2022-08-26 | 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 | 2022-08-04 | 2022-08-26 | 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 | 2022-08-04 | 2022-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-08-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-25 | 2019-08-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-02 | 2019-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-06-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-02 | 2019-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-02 | 2019-06-01 | 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 | 2019-05-02 | 2019-06-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-02 | 2019-06-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-02 | 2019-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-06-01 | N |
