A list of the most recent deficiencies for Shangri-La Rehab and Living 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 | 2023-08-24 | 2023-09-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-24 | 2023-09-20 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-24 | 2023-09-20 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-21 | 2023-09-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-21 | 2023-09-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-21 | 2023-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-21 | 2023-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-07-21 | 2023-09-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-21 | 2023-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-21 | 2023-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-21 | 2023-09-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-07-21 | 2023-09-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-21 | 2023-09-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-21 | 2023-09-01 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-07-21 | 2023-09-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-21 | 2023-09-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-07-21 | 2023-09-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-21 | 2023-09-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-28 | 2023-04-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-28 | 2023-03-28 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-04-07 | 2022-05-11 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-04-07 | 2022-05-11 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-04-07 | 2022-05-11 | 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 | 2022-04-07 | 2022-05-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-07 | 2022-05-11 | 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 | 2022-04-07 | 2022-05-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-07 | 2022-05-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-04-07 | 2022-05-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-07 | 2022-05-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-07 | 2022-05-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-05-11 | 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 | 2022-04-07 | 2022-05-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-07 | 2022-05-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-05-11 | 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 | 2022-04-07 | 2022-05-11 | N |
| Post nurse staffing information every day. | Health | 2022-04-07 | 2022-05-11 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-07 | 2022-05-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-07 | 2022-05-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-05-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-04-07 | 2022-05-11 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-07 | 2022-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-05-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-07 | 2022-05-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-07 | 2022-05-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-04-07 | 2022-05-11 | 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 | 2022-04-07 | 2022-05-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-07 | 2022-05-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-16 | 2022-01-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-20 | 2021-08-02 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-20 | 2021-08-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-19 | 2019-09-30 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-08-19 | 2019-09-30 | 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 | 2019-08-19 | 2019-09-30 | 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 | 2019-08-19 | 2019-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-19 | 2019-09-30 | 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 | 2019-08-19 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-19 | 2019-09-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-19 | 2019-09-30 | N |
