Deficiency Records for Shady Grove Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Shady Grove Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| 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 | 2022-06-02 | 2022-07-08 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-06-02 | 2022-07-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-09-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-02 | 2021-09-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-02 | 2021-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-01-15 | 2021-03-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-01-15 | 2021-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-01-15 | 2021-03-05 | 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 | 2021-01-15 | 2021-03-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-01-15 | 2021-03-05 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-01-15 | 2021-03-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-01-15 | 2021-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-15 | 2021-03-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-01-15 | 2021-03-05 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-01-15 | 2021-03-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-01-15 | 2021-03-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-01-15 | 2021-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-01-15 | 2021-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-01-15 | 2021-03-05 | 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 | 2021-01-19 | 2021-02-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-01-19 | 2021-02-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-01-19 | 2021-02-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-19 | 2021-02-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-01-19 | 2021-02-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-01-19 | 2021-02-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-20 | 2019-07-30 | 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 | 2019-05-20 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-20 | 2019-07-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-12 | 2019-05-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-12 | 2019-05-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-12 | 2019-05-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-12 | 2019-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-12 | 2019-05-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-12 | 2019-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-12 | 2019-05-24 | 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 | 2019-04-12 | 2019-05-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-12 | 2019-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-12 | 2019-05-24 | 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 | 2019-04-12 | 2019-05-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-12 | 2019-05-24 | 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 | 2019-04-12 | 2019-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-12 | 2019-05-24 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-04-12 | 2019-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-12 | 2019-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-12 | 2019-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-19 | 2018-06-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-19 | 2018-05-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-03-19 | 2018-05-18 | 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 | 2018-03-19 | 2018-05-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-03-19 | 2018-05-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-19 | 2018-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-19 | 2018-05-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-19 | 2018-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-19 | 2018-05-18 | 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 | 2018-03-19 | 2018-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-19 | 2018-05-18 | 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 | 2018-03-19 | 2018-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-19 | 2018-05-18 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-03-19 | 2018-05-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-19 | 2018-05-18 | N |
| Provide or obtain dental services for each resident. | Health | 2018-03-19 | 2018-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-19 | 2018-05-18 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2018-03-19 | 2018-05-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-19 | 2018-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-19 | 2018-05-18 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2018-03-19 | 2018-05-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-03-13 | 2018-05-18 | N |
| Meet other general requirements. | Fire Safety | 2018-03-13 | 2018-05-18 | 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 | 2018-03-13 | 2018-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-13 | 2018-05-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-13 | 2018-05-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-13 | 2018-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-13 | 2018-05-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-13 | 2018-05-18 | N |
