Deficiency Records for Shippenville Healthcare and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Shippenville Healthcare 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? |
|---|---|---|---|---|
| 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 | 2023-08-31 | 2023-10-10 | 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 | 2023-08-31 | 2023-10-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-31 | 2023-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Meet other general requirements. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-23 | 2023-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-23 | 2023-10-03 | 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 | 2023-02-06 | 2023-02-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-23 | 2022-10-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-23 | 2022-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-23 | 2022-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-10-31 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-28 | 2022-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-28 | 2022-10-31 | 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 | 2021-10-22 | 2021-12-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-22 | 2021-12-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-26 | 2021-11-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-26 | 2021-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-26 | 2021-11-18 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-10-26 | 2021-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-26 | 2021-11-18 | N |
