CMS Inspection Results for COMMONS AT SQUIRREL HILL, THE

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 12/05/2008 Health Survey for COMMONS AT SQUIRREL HILL, THE

Administration
Deficiency	Scope	Level of Harm
Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm

 

• 12/02/2008 Fire Safety Survey for COMMONS AT SQUIRREL HILL, THE

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm

 

• 03/07/2008 Health Survey for COMMONS AT SQUIRREL HILL, THE

Administration
Deficiency	Scope	Level of Harm
Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 03/06/2008 Fire Safety Survey for COMMONS AT SQUIRREL HILL, THE

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly constructed linen or trash chutes.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Potential for minimal harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Pattern	Potential for minimal harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Pattern	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Potential for minimal harm

 

• 10/30/2007 Fire Safety Survey for COMMONS AT SQUIRREL HILL, THE

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
rooms that can be unlocked from inside without a key.	Widespread	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
properly located and lighted Exit signs.	Widespread	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Widespread	Potential for minimal harm

 

• 10/23/2007 Health Survey for COMMONS AT SQUIRREL HILL, THE

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Immediate jeopardy to resident health or safety
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Actual harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	Widespread	Potential for minimal harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Listen to the resident or family groups or act on their complaints or suggestions.	Isolated	Minimal harm or potential for actual harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm