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Deficiency Records for Bayshore Residence and Rehabilitation Center
A list of the most recent deficiencies for Bayshore Residence and Rehabilitation Center. 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 Bayshore Residence 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-27 | 2024-07-06 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-22 | 2024-07-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-05-28 | 2024-06-21 | 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 | 2024-05-28 | 2024-06-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-28 | 2024-06-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-28 | 2024-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-28 | 2024-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-28 | 2024-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-28 | 2024-06-21 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-05-28 | 2024-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-28 | 2024-06-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-28 | 2024-06-21 | Y |
| 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 | 2024-05-22 | 2024-06-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-05-22 | 2024-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-20 | 2024-04-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-25 | 2023-08-18 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-06-23 | 2023-08-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-23 | 2023-08-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-23 | 2023-08-18 | N |
| 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 | 2023-06-23 | 2023-08-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-23 | 2023-08-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-23 | 2023-08-18 | 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 | 2023-06-23 | 2023-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-23 | 2023-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-23 | 2023-08-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-23 | 2023-08-18 | 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 | 2023-06-22 | 2023-08-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-22 | 2023-08-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-09 | 2023-03-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-09 | 2023-03-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-26 | 2022-10-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-26 | 2022-10-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-25 | 2022-05-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-25 | 2022-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-25 | 2022-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-25 | 2022-05-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-25 | 2022-05-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-25 | 2022-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-05-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-25 | 2022-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-05-10 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-25 | 2022-05-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-24 | 2022-05-10 | 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 | 2022-03-24 | 2022-05-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-24 | 2022-05-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-15 | 2022-05-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-10 | 2022-03-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-10 | 2022-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-04 | 2022-02-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-04 | 2022-02-04 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-04 | 2022-01-21 | Y |
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