A list of the most recent deficiencies for Shady Rest Care 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-27 | 2023-08-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-27 | 2023-08-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-27 | 2023-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-27 | 2023-08-25 | 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 | 2023-08-03 | 2023-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-03 | 2023-08-25 | 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 | 2023-01-05 | 2023-01-20 | 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 | 2022-11-28 | 2022-12-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-28 | 2022-12-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-28 | 2022-12-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-28 | 2022-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-28 | 2022-12-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-11-16 | 2022-12-21 | 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 | 2022-05-25 | 2022-07-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-07-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-07-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-25 | 2022-07-07 | 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 | 2022-05-25 | 2022-07-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-25 | 2022-07-07 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-05-25 | 2022-07-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-25 | 2022-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-07-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-25 | 2022-07-07 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-05-25 | 2022-07-07 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-05-25 | 2022-07-07 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-05-25 | 2022-07-07 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-05-25 | 2022-07-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-25 | 2022-07-07 | Y |
| 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 | 2022-05-19 | 2022-07-07 | 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 | 2022-05-19 | 2022-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-19 | 2022-07-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-19 | 2022-07-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-15 | 2022-01-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-15 | 2022-01-28 | 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 | 2021-12-15 | 2022-01-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-05 | 2021-09-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-21 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-08-05 | 2021-09-21 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-08-05 | 2021-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-26 | 2021-07-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-26 | 2021-07-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-26 | 2021-07-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-26 | 2021-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-07-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-26 | 2021-06-14 | Y |
| 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 | 2021-05-26 | 2021-06-14 | Y |
