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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? |
|---|---|---|---|---|
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-05 | 2021-10-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-05 | 2021-10-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-05 | 2021-10-28 | Y |
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