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Deficiency Records for South Shore Rehabilitation
A list of the most recent deficiencies for South Shore Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for South Shore 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? |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-13 | 2024-09-14 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2024-07-31 | 2024-08-16 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
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 | 2024-07-31 | 2024-08-13 | 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 | 2024-07-31 | 2024-08-13 | N |
Provide properly protected cooking facilities. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-07-31 | 2024-08-13 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-26 | 2024-08-09 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-26 | 2024-08-09 | 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 | 2024-07-26 | 2024-08-09 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-07-26 | 2024-08-09 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-07-26 | 2024-08-09 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-07-26 | 2024-08-09 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-07-26 | 2024-08-09 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-26 | 2024-08-09 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-26 | 2024-08-09 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-26 | 2024-08-09 | 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 | 2024-07-26 | 2024-08-09 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-26 | 2024-08-09 | N |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-07-26 | 2024-08-09 | N |
Provide and implement an infection prevention and control program. | Health | 2024-07-26 | 2024-08-09 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-26 | 2024-08-09 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-26 | 2024-08-09 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-07-26 | 2024-08-09 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-05 | 2024-06-10 | 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 | 2024-06-05 | 2024-06-10 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-05 | 2024-06-10 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-26 | 2024-02-06 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-18 | 2023-12-19 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2023-12-19 | Y |
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 | 2023-09-29 | 2023-10-13 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-29 | 2023-10-13 | Y |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-09-29 | 2023-10-13 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-29 | 2023-10-13 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-29 | 2023-10-13 | Y |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-11 | 2023-08-03 | N |
Use approved construction type or materials. | Fire Safety | 2023-07-11 | 2023-08-03 | 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 | 2023-07-11 | 2023-08-03 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-07-11 | 2023-08-03 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-11 | 2023-08-03 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-11 | 2023-08-03 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-11 | 2023-08-03 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-07-11 | 2023-08-03 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-14 | 2023-07-07 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-14 | 2023-07-07 | 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 | 2023-06-14 | 2023-07-07 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-14 | 2023-07-07 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-14 | 2023-07-07 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-14 | 2023-07-07 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-14 | 2023-07-07 | 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 | 2023-06-14 | 2023-07-07 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-14 | 2023-07-07 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-14 | 2023-07-07 | N |
Put firmly secured handrails on each side of hallways. | Health | 2023-06-14 | 2023-07-07 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-09 | 2023-04-13 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-03 | 2023-03-17 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-03 | 2023-03-17 | Y |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-09 | 2023-02-15 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-09 | 2023-02-15 | 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 | 2023-02-09 | 2023-02-15 | Y |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-09 | 2023-02-15 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-23 | 2023-01-03 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-28 | 2022-11-14 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-28 | 2022-11-14 | Y |
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2022-10-28 | 2022-11-14 | 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 | 2022-09-16 | 2022-09-23 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-01 | 2022-08-24 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-28 | 2022-08-09 | Y |
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 | 2022-07-28 | 2022-08-09 | Y |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-07-28 | 2022-08-09 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-10 | 2022-06-21 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-10 | 2022-06-21 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-10 | 2022-06-21 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-10 | 2022-06-21 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Establish policies and procedures for medical documentation. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Create arrangements with other facilities to receive patients. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
List the names and contact information of those in the facility. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Establish staff and initial training requirements. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Implement emergency and standby power systems. | Fire Safety | 2022-06-01 | 2022-06-20 | 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 | 2022-06-01 | 2022-06-20 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-01 | 2022-06-20 | 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 | 2022-06-01 | 2022-06-20 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have restrictions on the use of portable space heaters. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Ensure proper storage of liquid oxygen. | Fire Safety | 2022-06-01 | 2022-06-20 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-06-06 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-25 | 2022-06-06 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-25 | 2022-06-06 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-06-06 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-25 | 2022-06-06 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-25 | 2022-06-06 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-06-06 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-25 | 2022-06-06 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-25 | 2022-06-06 | 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 | 2022-05-25 | 2022-06-06 | N |
Dispose of garbage and refuse properly. | Health | 2022-05-25 | 2022-06-06 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-11 | 2022-05-18 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-23 | 2022-04-01 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-11-03 | Y |
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