Deficiency Records for Shirkey Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Shirkey 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-16 | 2022-09-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-20 | 2022-06-02 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-04-20 | 2022-06-02 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-20 | 2022-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-20 | 2022-06-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-20 | 2022-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-20 | 2022-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-20 | 2022-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-20 | 2022-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-20 | 2022-06-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-20 | 2022-06-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-20 | 2022-06-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-20 | 2022-06-02 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-20 | 2022-06-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-20 | 2022-06-02 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Meet other general requirements. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | 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 | 2022-04-20 | 2022-06-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-20 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-11-27 | Y |
| Report COVID19 data to residents and families. | Health | 2021-11-02 | 2021-11-27 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-02 | 2021-11-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-27 | 2021-10-26 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-27 | 2021-10-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-06 | 2019-06-04 | N |
| Post nurse staffing information every day. | Health | 2019-03-06 | 2019-06-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-06 | 2019-06-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-06 | 2019-06-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-06 | 2019-06-04 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-03-06 | 2019-04-20 | 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 | 2019-03-06 | 2019-04-20 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-03-06 | 2019-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-06 | 2019-04-20 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-06 | 2019-04-20 | 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 | 2019-03-06 | 2019-04-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-06 | 2019-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-06 | 2019-04-20 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-06 | 2019-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-06 | 2019-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-06 | 2019-04-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-22 | 2018-05-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-22 | 2018-05-05 | 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 | 2018-03-22 | 2018-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-22 | 2018-05-05 | 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 | 2018-03-22 | 2018-05-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-22 | 2018-05-05 | 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 | 2018-03-22 | 2018-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-22 | 2018-05-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-22 | 2018-05-05 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-03-22 | 2018-05-05 | 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 | 2018-03-22 | 2018-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-22 | 2018-05-05 | N |
