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Deficiency Records for Avamere Rehabilitation of Shoreline
A list of the most recent deficiencies for Avamere Rehabilitation of Shoreline. 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 Avamere Rehabilitation of Shoreline. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-12 | 2024-09-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-12 | 2024-09-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-09 | 2024-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-09 | 2024-07-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-24 | 2024-07-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-24 | 2024-07-22 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2024-03-13 | 2024-05-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Develop a communication plan. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-13 | 2024-05-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-03-13 | 2024-05-07 | 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 | 2024-03-19 | 2024-04-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-19 | 2024-04-26 | N |
| 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 | 2024-03-19 | 2024-04-26 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-19 | 2024-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-19 | 2024-04-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-19 | 2024-04-26 | 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 | 2024-03-19 | 2024-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-19 | 2024-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-19 | 2024-04-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-19 | 2024-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-19 | 2024-04-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-03-19 | 2024-04-26 | N |
| Post nurse staffing information every day. | Health | 2024-03-19 | 2024-04-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-19 | 2024-04-26 | 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 | 2024-03-19 | 2024-04-26 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-19 | 2024-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-19 | 2024-04-26 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-03-19 | 2024-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-19 | 2024-04-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-19 | 2024-04-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-03-19 | 2024-04-26 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-14 | 2024-03-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-20 | 2023-10-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-28 | 2023-08-28 | Y |
| 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 | 2022-12-20 | 2023-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-20 | 2023-03-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-20 | 2023-03-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-20 | 2023-03-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-20 | 2023-03-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-20 | 2023-02-24 | N |
| Develop a communication plan. | Fire Safety | 2022-12-20 | 2023-02-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-12-20 | 2023-02-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-20 | 2023-02-20 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-12-20 | 2023-02-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-22 | 2023-02-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-22 | 2023-02-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-12-20 | 2023-01-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-22 | 2023-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-20 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-20 | 2023-01-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-22 | 2023-01-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-12-22 | 2023-01-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-22 | 2023-01-19 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-12-22 | 2023-01-19 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-12-22 | 2023-01-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-01-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-22 | 2023-01-19 | N |
| 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 | 2022-12-22 | 2023-01-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-22 | 2023-01-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-22 | 2023-01-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-22 | 2023-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-20 | 2023-01-12 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-12-20 | 2023-01-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-20 | 2023-01-02 | N |
| Meet other general requirements. | Fire Safety | 2022-12-20 | 2022-12-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-19 | 2022-10-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-19 | 2022-10-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-19 | 2022-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-27 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-11 | 2022-03-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-24 | 2022-02-11 | Y |
| 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 | 2019-10-31 | 2019-11-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-31 | 2019-11-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-08 | 2019-11-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-08 | 2019-11-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-08 | 2019-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-08 | 2019-11-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-08 | 2019-11-25 | 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 | 2019-11-08 | 2019-11-25 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-08 | 2019-11-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-08 | 2019-11-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-08 | 2019-11-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-31 | 2019-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-31 | 2019-11-14 | N |
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