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Trinity Mission Health & Rehab Of Shenandoah Hgts
200 PENNSYLVANIA AVENUE
Shenandoah, PA 17976
(570) 462-1921
General
Ratings
Deficiencies
Resident Stats
Staff Stats
| Certified Beds: | 111 |
| Number of Residents: | 78 |
| Percent of Occupied Beds: | 70% |
| Sprinkler Status: | Not Sprinklered |
| Program Participation: | Medicare and Medicaid |
| Type of Ownership: | For profit - Limited liability company |
| Located Within a Hospital? | No |
| Multi Nursing Home Ownership? | Yes |
| Resident and Family Councils? | Resident |
| Continuing Care Retirement Community? | No |
| Quality Indicator Survey? | No |
| Special Focus Facility? | Yes |
| Overall: |  |
| Health Inspection: |  |
| Nurse Staffing: |  |
| Quality Measures: | |
| RN Only: |  |
| Date | Type | Category | Deficiency | Scope | Level of Harm | Date of Correction |
| 20070917 | Health | Pharmacy Service Deficiencies | 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Pattern | Minimal harm or potential for actual harm | 20071023 |
| 20080507 | Health | Resident Rights Deficiencies | Give the resident's legal representative the same rights as the resident. | Isolated | Minimal harm or potential for actual harm | 20080516 |
| 20081010 | Health | Quality Care Deficiencies | Provide activities to meet the needs of each resident. | Pattern | Minimal harm or potential for actual harm | 20090225 |
| 20081010 | Health | Environmental Deficiencies | Provide needed housekeeping and maintenance. | Isolated | Minimal harm or potential for actual harm | 20090225 |
| 20081010 | Health | Administration Deficiencies | post nurse staffing information. | Widespread | Potential for minimal harm | 20090225 |
| 20081120 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Isolated | Minimal harm or potential for actual harm | 20090317 |
| 20081120 | Health | Quality Care Deficiencies | Give each resident care and services to get or keep the highest quality of life possible. | Pattern | Minimal harm or potential for actual harm | 20090225 |
| 20081120 | Health | Quality Care Deficiencies | Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion. | Pattern | Minimal harm or potential for actual harm | 20090225 |
| 20081120 | Health | Quality Care Deficiencies | Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Isolated | Minimal harm or potential for actual harm | 20090225 |
| 20081120 | Health | Resident Rights Deficiencies | Give the resident's legal representative the same rights as the resident. | Pattern | Minimal harm or potential for actual harm | 20090317 |
| 20081120 | Health | Resident Rights Deficiencies | 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. | Pattern | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Resident Rights Deficiencies | 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 | 20090317 |
| 20081218 | Health | Resident Assessment Deficiencies | 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 | 20090317 |
| 20081218 | Health | Resident Rights Deficiencies | Give the resident's legal representative the same rights as the resident. | Isolated | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Quality Care Deficiencies | Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. | Pattern | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Mistreatment Deficiencies | 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. | Pattern | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Quality Care Deficiencies | Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Isolated | Actual harm | 20090317 |
| 20081218 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Pattern | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Nutrition and Dietary Deficiencies | Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Widespread | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Administration Deficiencies | Set up or keep a group of people to review and ensure quality. | Pattern | Minimal harm or potential for actual harm | 20090317 |
| 20081218 | Health | Environmental Deficiencies | Keep all essential equipment working safely. | Pattern | Minimal harm or potential for actual harm | 20090225 |
| 20090130 | Health | Environmental Deficiencies | Keep temperature levels comfortable and safe. | Pattern | Minimal harm or potential for actual harm | 20090225 |
| 20090130 | Health | Mistreatment Deficiencies | 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 | Minimal harm or potential for actual harm | 20090317 |
| 20090916 | Health | Resident Assessment Deficiencies | Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | Pattern | Minimal harm or potential for actual harm | 20091117 |
| 20090916 | Health | Administration Deficiencies | Have a detailed, written plan for disasters and emergencies. | Pattern | Minimal harm or potential for actual harm | 20091117 |
| 20090923 | Health | Pharmacy Service Deficiencies | At least once a month, have a licensed pharmacist check the drugs that each resident takes. | Isolated | Minimal harm or potential for actual harm | 20091117 |
| 20090923 | Health | Environmental Deficiencies | Make sure that the nursing home area is free of dangers that cause accidents. | Pattern | Minimal harm or potential for actual harm | 20091117 |
| 20090923 | Health | Pharmacy Service Deficiencies | 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Pattern | Minimal harm or potential for actual harm | 20091117 |
| 20091015 | Health | Quality Care Deficiencies | 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 | 20091117 |
| 20091015 | Health | Resident Rights Deficiencies | Protect the resident from a transfer or discharge that is not wanted or needed. | Isolated | Minimal harm or potential for actual harm | 20091117 |
| 20091029 | Health | Quality Care Deficiencies | 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 | 20091117 |
| 20091029 | Health | Quality Care Deficiencies | Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Isolated | Minimal harm or potential for actual harm | 20091117 |
| 20091029 | Health | Pharmacy Service Deficiencies | At least once a month, have a licensed pharmacist check the drugs that each resident takes. | Pattern | Minimal harm or potential for actual harm | 20091117 |
| 20091029 | Health | Administration Deficiencies | Train all employees on what to do in an emergency. | Pattern | Minimal harm or potential for actual harm | 20091117 |
| 20100702 | Health | Resident Rights Deficiencies | Try to resolve each resident's complaints quickly. | Pattern | Minimal harm or potential for actual harm | 20100921 |
| 20100827 | Health | Quality Care Deficiencies | Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Pattern | Minimal harm or potential for actual harm | 20100921 |
| Value | Notes | |
| Percent of long-stay residents given influenza vaccination during the flu season: | 99 | |
| Percent of long-stay residents who were assessed and given pneumococcal vaccination: | 100 | |
| Percent of long-stay residents whose need for help with daily activities has increased: | 13 | |
| Percent of long-stay residents who have moderate to severe pain: | 2 | |
| Percent of high-risk long-stay residents who have pressure sores: | 15 | |
| Percent of low-risk long-stay residents who have pressure sores: | 3 | |
| Percent of long-stay residents who were physically restrained: | 5 | |
| Percent of long-stay residents who are more depressed or anxious: | 10 | |
| Percent of low-risk long-stay residents who lose control of their bowels or bladder: | 47 | |
| Percent of long-stay residents who have/had a catheter inserted and left in their bladder: | 3 | |
| Percent of long-stay residents who spend most of their time in bed or in a chair: | 0 | |
| Percent of long-stay residents whose ability to move about in and around their room got worse: | 8 | |
| Percent of long-stay residents who had a urinary tract infection: | 7 | |
| Percent of long-stay residents who lose too much weight: | 6 | |
| Percent of short-stay residents given influenza vaccination during the flu season: | 97 | |
| Percent of short-stay residents who were assessed and given pneumococcal vaccination: | 100 | |
| Percent of short-stay residents who have delirium: | 1 | |
| Percent of short-stay residents who had moderate to severe pain: | 10 | |
| Percent of short-stay residents who have pressure sores: | 18 | |
| # of Residents: | 78 |
| # RN Hours per Resident: | 0.69 |
| # LPN Hours per Resident: | 1.18 |
| # CNA Hours per Resident: | 2.5 |
| Total Staff Hours per Resident: | 1.87 |
