Deficiency Records for Shady Acres Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Shady Acres 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? |
|---|---|---|---|---|
| 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 | 2024-01-30 | 2024-02-21 | 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 | 2024-01-30 | 2024-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-20 | 2024-02-15 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-20 | 2024-02-01 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-20 | 2024-01-10 | Y |
| 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 | 2023-12-20 | 2024-01-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-20 | 2024-01-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-19 | 2023-01-31 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-19 | 2023-01-31 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-18 | 2022-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-18 | 2022-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-18 | 2022-11-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-19 | 2022-11-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-06 | 2022-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-01 | 2022-08-02 | 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 | 2022-08-01 | 2022-08-02 | Y |
| 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 | 2021-08-19 | 2021-10-18 | 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 | 2021-08-31 | 2021-10-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-08-19 | 2021-09-17 | 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 | 2021-08-19 | 2021-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-01 | 2021-03-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-01 | 2021-03-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-01 | 2021-03-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-01 | 2021-03-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-01 | 2021-03-26 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-01 | 2021-03-26 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-03-01 | 2021-03-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-01 | 2021-03-15 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-30 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-18 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-31 | Not Fixed | N |
