Deficiency Records for North Hills Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for North Hills Health 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-16 | 2023-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-16 | 2023-12-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-11-16 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-15 | 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 | 2023-03-24 | 2023-04-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-28 | 2023-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-22 | 2023-01-09 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-12-22 | 2023-01-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-22 | 2023-01-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-22 | 2023-01-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-12-22 | 2023-01-09 | 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 | 2022-12-22 | 2023-01-09 | N |
| 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 | 2022-12-22 | 2023-01-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-22 | 2023-01-09 | 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 | 2022-12-22 | 2023-01-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-22 | 2023-01-09 | 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 | 2022-12-22 | 2023-01-09 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-22 | 2023-01-09 | N |
| 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 | 2022-12-22 | 2023-01-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-14 | 2022-12-09 | 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 | 2022-10-07 | 2022-11-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-07 | 2022-11-03 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-10-07 | 2022-11-03 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-10-07 | 2022-11-03 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-10-07 | 2022-11-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-09 | 2022-01-15 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-12-09 | 2022-01-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-09 | 2022-01-15 | 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 | 2021-12-09 | 2022-01-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-09 | 2022-01-15 | N |
