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Deficiency Records for Complete Care at Shrewsbury LLC
A list of the most recent deficiencies for Complete Care at Shrewsbury LLC. 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 Complete Care at Shrewsbury LLC. 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? |
|---|---|---|---|---|
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2024-07-23 | 2024-08-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-30 | 2024-07-19 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-30 | 2024-07-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-30 | 2024-07-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-30 | 2024-07-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-30 | 2024-07-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-30 | 2024-07-02 | 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 | 2024-05-30 | 2024-07-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-30 | 2024-07-02 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-30 | 2024-07-02 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-30 | 2024-07-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-30 | 2024-07-02 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-05-30 | 2024-07-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-30 | 2024-07-02 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-03-10 | 2022-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-10 | 2022-04-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-10 | 2022-04-10 | 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 | 2022-03-10 | 2022-04-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-10 | 2022-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-10 | 2022-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-17 | 2022-02-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-17 | 2022-02-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-26 | 2020-01-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-26 | 2020-01-01 | N |
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