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Deficiency Records for Shuksan Rehabilitation and Health Care
View the most recent health deficiencies and inspection results for Shuksan Rehabilitation and Health Care. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Shuksan Rehabilitation and Health Care. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2026-03-18 | 2026-04-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-03-18 | 2026-04-17 | 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 | 2026-03-18 | 2026-04-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2026-03-18 | 2026-04-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-09-04 | 2025-11-03 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2025-07-11 | 2025-08-29 | Y |
| Develop a communication plan. | Fire Safety | 2025-05-01 | 2025-06-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2025-05-01 | 2025-06-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-05-01 | 2025-06-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2025-05-01 | 2025-06-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-05-01 | 2025-06-09 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2025-05-01 | 2025-06-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-05-01 | 2025-06-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-05-01 | 2025-06-04 | 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 | 2025-05-01 | 2025-06-04 | 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 | 2025-05-01 | 2025-06-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-05-01 | 2025-06-04 | N |
| 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 | 2025-05-01 | 2025-06-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-05-01 | 2025-06-04 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2025-05-01 | 2025-06-04 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2025-05-01 | 2025-06-04 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2025-05-01 | 2025-06-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-05-01 | 2025-06-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-05-01 | 2025-06-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-05-01 | 2025-06-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-05-01 | 2025-06-04 | 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 | 2025-05-01 | 2025-06-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-05-01 | 2025-06-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2025-05-01 | 2025-06-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-05-01 | 2025-06-04 | N |
| Respond appropriately to all alleged violations. | Health | 2025-05-01 | 2025-06-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-01 | 2025-06-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2025-05-01 | 2025-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-11 | 2025-04-20 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-16 | 2024-08-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-16 | 2024-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-16 | 2024-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-16 | 2024-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-16 | 2024-08-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-16 | 2024-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-16 | 2024-07-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-16 | 2024-07-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-16 | 2024-07-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-16 | 2024-07-22 | 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 | 2024-05-16 | 2024-07-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-16 | 2024-07-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-05-16 | 2024-07-22 | 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 | 2024-05-16 | 2024-07-22 | 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 | 2024-05-16 | 2024-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-16 | 2024-07-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-16 | 2024-07-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-05-16 | 2024-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-16 | 2024-07-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-16 | 2024-07-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-05-16 | 2024-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-16 | 2024-06-15 | 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 | 2024-05-16 | 2024-06-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-05-16 | 2024-06-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-14 | 2024-04-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-14 | 2024-04-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-06 | 2024-04-17 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-03-06 | 2024-04-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2024-01-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-01-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-13 | 2023-08-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-13 | 2023-08-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-21 | 2023-07-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-21 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-17 | 2023-03-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-17 | 2023-03-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-17 | 2023-03-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-17 | 2023-03-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Develop a communication plan. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Meet other general requirements. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-17 | 2023-03-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-17 | 2023-03-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-17 | 2023-03-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-17 | 2023-03-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-17 | 2023-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-17 | 2023-03-01 | N |