CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Shady Grove Nursing and Rehabilitation Center
View the most recent health deficiencies and inspection results for Shady Grove Nursing and Rehabilitation Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Shady Grove Nursing and Rehabilitation Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-13 | 2026-05-19 | 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 | 2025-12-19 | 2026-01-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-12-19 | 2026-01-27 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-06-16 | 2025-08-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-06-16 | 2025-08-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-16 | 2025-08-14 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-06-16 | 2025-08-14 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2025-07-17 | 2025-08-11 | Y |
| 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 | 2025-03-13 | 2025-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-13 | 2025-05-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-03-13 | 2025-05-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2025-03-13 | 2025-05-05 | 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 | 2025-03-13 | 2025-05-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2025-03-13 | 2025-05-05 | N |
| 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 | 2025-03-13 | 2025-05-05 | 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 | 2025-03-13 | 2025-05-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-03-13 | 2025-05-05 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2025-03-13 | 2025-05-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2025-03-13 | 2025-05-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-03-13 | 2025-05-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-03-13 | 2025-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-13 | 2025-05-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-03-13 | 2025-05-05 | N |
| Keep all essential equipment working safely. | Health | 2025-03-13 | 2025-05-05 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2025-03-13 | 2025-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-03-13 | 2025-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-03-13 | 2025-05-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-03-13 | 2025-05-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-03-13 | 2025-05-05 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2025-03-13 | 2025-05-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-13 | 2025-05-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-03-13 | 2025-05-05 | 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 | 2025-03-13 | 2025-05-05 | Y |
| 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 | 2025-03-13 | 2025-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-13 | 2025-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-13 | 2025-05-05 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2025-03-13 | 2025-05-05 | 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 | 2025-03-13 | 2025-05-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-03-13 | 2025-05-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-13 | 2025-05-05 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2025-03-13 | 2025-05-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2025-03-13 | 2025-05-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-03-13 | 2025-05-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-03-13 | 2025-05-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Meet other general requirements. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-13 | 2025-03-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-26 | 2024-04-29 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-03-26 | 2024-04-29 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-03-26 | 2024-04-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-26 | 2024-04-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-26 | 2024-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-26 | 2024-04-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-26 | 2024-04-29 | 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 | 2024-03-26 | 2024-04-29 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-26 | 2024-04-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-26 | 2024-04-29 | Y |
| 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 |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-15 | 2021-02-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-01-15 | 2021-02-09 | 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 | 2021-01-15 | 2021-02-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-01-15 | 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 | 2021-01-15 | 2021-02-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-01-15 | 2021-02-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-12 | 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 | 2019-04-12 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-12 | 2019-07-30 | N |
| Provide and implement an infection prevention and control program. | 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 |
| 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 |
| 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 |
| 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 |
| Ensure medication error rates are not 5 percent or greater. | 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 |
| 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 |