Deficiency Records for Squirrel Hill Wellness and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Squirrel Hill Wellness 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 a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-12 | 2023-11-29 | 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 | 2023-07-20 | 2023-08-30 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-07-20 | 2023-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-08-30 | Y |
| 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 | 2023-07-20 | 2023-08-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-07-03 | 2023-07-07 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-17 | 2023-07-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-17 | 2023-07-03 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-17 | 2023-07-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-17 | 2023-07-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-06 | 2023-04-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-06 | 2023-04-19 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-06 | 2023-04-19 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-06 | 2023-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-06 | 2023-04-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-06 | 2023-04-19 | 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 | 2023-03-06 | 2023-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-06 | 2023-04-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-06 | 2023-04-19 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-03-06 | 2023-04-19 | 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 | 2023-03-06 | 2023-04-19 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-06 | 2023-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-06 | 2023-04-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-06 | 2023-04-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-06 | 2023-04-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-06 | 2023-04-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-06 | 2023-04-19 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-06 | 2023-04-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-02 | 2023-04-11 | N |
| Dispose of garbage and refuse properly. | Health | 2023-02-09 | 2023-02-28 | 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 | 2023-01-19 | 2023-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-30 | 2022-12-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-27 | 2022-10-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-27 | 2022-10-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-27 | 2022-10-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-10-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-26 | 2022-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-26 | 2022-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-26 | 2022-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-16 | 2022-05-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-16 | 2022-05-17 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-16 | 2022-05-17 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-14 | 2022-04-16 | 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 | 2022-03-14 | 2022-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-14 | 2022-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-14 | 2022-04-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-14 | 2022-04-16 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-03-14 | 2022-04-16 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-03-14 | 2022-04-16 | 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 | 2022-03-14 | 2022-04-16 | Y |
| 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 | 2022-03-14 | 2022-04-16 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-14 | 2022-04-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-14 | 2022-04-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-03-14 | 2022-04-06 | 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 | 2022-03-14 | 2022-04-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-14 | 2022-04-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-14 | 2022-04-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-14 | 2022-04-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-14 | 2022-04-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-03-14 | 2022-04-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-01 | 2021-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-01 | 2021-11-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-23 | 2021-10-25 | 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 | 2021-09-23 | 2021-10-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-23 | 2021-10-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-23 | 2021-10-25 | 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 | 2021-09-23 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-23 | 2021-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-23 | 2021-10-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-23 | 2021-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-10-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-16 | 2021-08-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-16 | 2021-08-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-28 | 2021-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-28 | 2021-05-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-22 | Y |
| 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 | 2021-04-28 | 2021-05-22 | 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 | 2021-04-28 | 2021-05-22 | Y |
| 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 | 2021-04-28 | 2021-05-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-28 | 2021-05-22 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-04-28 | 2021-05-22 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-04-28 | 2021-05-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-05-22 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-28 | 2021-05-22 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-04-28 | 2021-05-22 | Y |
