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Deficiency Records for Shoreline Health and Rehabilitation
A list of the most recent deficiencies for Shoreline Health and 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 Shoreline Health and 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 heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-06 | 2023-12-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Establish methods for sharing information. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-06 | 2023-11-14 | 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 | 2023-10-06 | 2023-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-06 | 2023-11-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-06 | 2023-11-14 | 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 | 2023-10-02 | 2023-10-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-02 | 2023-10-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-02 | 2023-10-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-02 | 2023-10-25 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-10-02 | 2023-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-02 | 2023-10-25 | 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 | 2023-10-02 | 2023-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-02 | 2023-10-25 | N |
| Post nurse staffing information every day. | Health | 2023-10-02 | 2023-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-02 | 2023-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-02 | 2023-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-02 | 2023-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-03-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-16 | 2022-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-07-11 | N |
| Post nurse staffing information every day. | Health | 2022-06-16 | 2022-07-11 | 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 | 2022-06-16 | 2022-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-16 | 2022-07-11 | N |
| Use approved construction type or materials. | Fire Safety | 2022-06-22 | 2022-07-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-22 | 2022-07-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-22 | 2022-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-22 | 2022-07-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-07 | 2022-04-08 | 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 | 2022-04-07 | 2022-04-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-05 | 2020-01-22 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-12-05 | 2020-01-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-05 | 2020-01-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-05 | 2020-01-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-05 | 2020-01-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-05 | 2020-01-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-05 | 2020-01-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-05 | 2020-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-05 | 2020-01-22 | N |
| Post nurse staffing information every day. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-12-05 | 2020-01-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-12-05 | 2020-01-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-05 | 2020-01-22 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-12-05 | 2020-01-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-05 | 2020-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-01-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-12-05 | 2020-01-22 | 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 | 2019-11-19 | 2019-12-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-19 | 2019-12-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-19 | 2019-12-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-19 | 2019-12-03 | N |
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