Deficiency Records for North Hills Skilled Nursing and Rehabilitation Ctr
Updated as of April 01, 2024
A list of the most recent deficiencies for North Hills Skilled Nursing and Rehabilitation Ctr. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-12 | 2024-03-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-01-12 | 2024-03-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-12 | 2024-03-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-12 | 2024-03-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-12 | 2024-03-06 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-12 | 2024-03-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-12 | 2024-03-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-12 | 2024-03-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-12 | 2024-03-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-12 | 2024-03-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-12 | 2024-03-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-12 | 2024-03-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-12 | 2024-03-06 | 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 | 2024-01-12 | 2024-03-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-01-12 | 2024-03-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-12 | 2024-03-06 | 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 | 2024-01-12 | 2024-03-06 | 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 | 2024-01-12 | 2024-03-06 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-01-12 | 2024-03-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-12 | 2024-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-12 | 2024-03-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-12 | 2024-03-06 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-01-12 | 2024-03-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-10 | 2024-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-10 | 2024-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-10 | 2024-02-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-07 | 2023-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-07 | 2023-12-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-29 | 2023-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-29 | 2023-10-18 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-09-29 | 2023-10-18 | 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 | 2023-07-11 | 2023-08-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-16 | 2023-07-06 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-16 | 2023-07-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-16 | 2023-07-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-30 | 2023-03-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-30 | 2023-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-30 | 2023-03-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-30 | 2023-03-15 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-30 | 2023-03-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-30 | 2023-03-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-30 | 2023-03-15 | 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 | 2023-01-30 | 2023-03-15 | 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 | 2023-01-30 | 2023-03-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-30 | 2023-03-15 | N |
| 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 | 2023-01-30 | 2023-03-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-30 | 2023-03-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-30 | 2023-03-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-04 | 2022-11-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-08 | 2022-09-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-08 | 2022-09-28 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-03-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-28 | 2022-03-24 | N |
| 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 | 2022-01-14 | 2022-02-22 | 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 | 2022-01-14 | 2022-02-22 | 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 | 2022-01-14 | 2022-02-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-14 | 2022-02-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-15 | 2021-08-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-15 | 2021-08-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-03 | Y |
