A list of the most recent deficiencies for Shady Lawn Nursing Home. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2022-08-04 | 2022-09-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-04 | 2022-09-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-08-04 | 2022-09-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-04 | 2022-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-04 | 2022-09-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-13 | 2022-05-31 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-01-28 | 2022-02-22 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-12 | 2019-10-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-08-15 | 2019-10-10 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-08-15 | 2019-10-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-15 | 2019-10-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-15 | 2019-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-15 | 2019-10-10 | 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 | 2019-08-15 | 2019-10-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-12 | 2019-10-10 | 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 | 2019-08-12 | 2019-10-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-08-12 | 2019-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-12 | 2019-10-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-12 | 2019-10-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-12 | 2019-10-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-12 | 2019-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-12 | 2019-10-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-08-12 | 2019-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-28 | 2018-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-28 | 2018-07-20 | N |
| Provide activities to meet all resident's needs. | Health | 2018-06-28 | 2018-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-28 | 2018-07-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-06-28 | 2018-07-20 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2018-06-28 | 2018-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-28 | 2018-07-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-06-28 | 2018-07-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-06-26 | 2018-07-20 | 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 | 2018-06-26 | 2018-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-26 | 2018-07-20 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2018-06-26 | 2018-07-20 | N |
