Deficiency Records for Shady Oak Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Shady Oak Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-07-18 | 2023-08-11 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-07-14 | 2023-08-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-14 | 2023-08-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-07-14 | 2023-08-09 | 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 | 2023-07-14 | 2023-08-09 | 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 | 2023-07-14 | 2023-08-09 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-14 | 2023-08-09 | N |
| Provide training in compliance and ethics. | Health | 2023-07-14 | 2023-08-09 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-14 | 2023-08-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-18 | 2023-07-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-18 | 2023-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-18 | 2023-07-19 | 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 | 2022-06-16 | 2022-06-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-16 | 2022-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-16 | 2022-06-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-16 | 2022-06-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-16 | 2022-06-17 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-09-15 | 2021-09-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-15 | 2021-09-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-15 | 2021-09-16 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-07 | 2021-04-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-04-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-07 | 2021-04-08 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-04-07 | 2021-04-08 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-07 | 2021-04-08 | Y |
| 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 | 2021-04-07 | 2021-04-08 | Y |
