A list of the most recent deficiencies for Village Shalom Inc. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-15 | 2023-12-15 | 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 | 2023-11-15 | 2023-12-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-19 | 2023-11-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-19 | 2023-11-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-19 | 2023-11-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-19 | 2023-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-19 | 2023-11-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-19 | 2023-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2023-11-20 | 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 | 2023-10-19 | 2023-11-20 | 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 | 2023-10-19 | 2023-11-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-19 | 2023-11-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-19 | 2023-11-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-19 | 2023-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-03 | 2023-08-29 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-16 | 2022-04-22 | 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 | 2022-03-16 | 2022-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-02-07 | 2022-03-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-07 | 2022-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-07 | 2022-03-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-07 | 2022-03-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-16 | 2020-04-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-16 | 2020-04-14 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-16 | 2020-04-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-03-16 | 2020-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-16 | 2020-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-16 | 2020-04-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-16 | 2020-04-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-03-16 | 2020-04-14 | 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 | 2020-03-16 | 2020-04-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-16 | 2020-04-14 | 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 | 2020-03-16 | 2020-04-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-16 | 2020-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-16 | 2020-04-14 | 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 | 2020-03-12 | 2020-03-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-12 | 2020-03-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-03-12 | 2020-03-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-12 | 2020-03-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-12 | 2020-03-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-12 | 2020-03-28 | N |
