A list of the most recent deficiencies for First Shamrock 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-19 | 2023-10-27 | 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 | 2023-09-19 | 2023-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-19 | 2023-10-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-10-27 | 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 | 2023-06-27 | 2023-09-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-27 | 2023-09-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-27 | 2023-09-26 | N |
| 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 | 2023-06-27 | 2023-09-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-27 | 2023-09-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-27 | 2023-09-26 | Y |
| 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 | 2023-06-27 | 2023-09-26 | Y |
| 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 | 2022-06-29 | 2022-08-12 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-06-29 | 2022-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-03-21 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-11-09 | 2021-11-23 | Y |
| 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 | 2020-03-05 | 2020-04-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-03-05 | 2020-04-30 | 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 | 2020-03-05 | 2020-04-30 | 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 | 2020-03-05 | 2020-04-30 | N |
| 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 | 2020-03-05 | 2020-04-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-03-05 | 2020-04-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-03-05 | 2020-04-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-03-05 | 2020-04-30 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Establish methods for sharing information. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-03-03 | 2020-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-03 | 2020-04-30 | 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 | 2019-01-29 | 2019-03-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-29 | 2019-03-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-01-29 | 2019-03-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-29 | 2019-03-26 | 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 | 2019-01-29 | 2019-03-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-29 | 2019-03-26 | 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 | 2019-01-29 | 2019-03-26 | 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 | 2019-01-29 | 2019-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-29 | 2019-03-26 | 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 | 2019-01-29 | 2019-03-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-01-29 | 2019-03-26 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-01-23 | 2019-03-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-23 | 2019-03-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-01-23 | 2019-03-26 | N |
