Deficiency Records for North Shore Health and Rehab Facility
Updated as of March 01, 2024
A list of the most recent deficiencies for North Shore Health and Rehab Facility. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-26 | 2023-08-15 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-26 | 2023-08-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-26 | 2023-08-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-26 | 2023-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-26 | 2022-08-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-07-26 | 2022-08-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-09-11 | 2020-10-28 | 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 | 2020-09-11 | 2020-10-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2020-09-11 | 2020-10-24 | N |
| Use approved construction type or materials. | Fire Safety | 2020-09-11 | 2020-09-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-10 | 2020-04-30 | 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 | 2020-03-10 | 2020-04-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-03-10 | 2020-04-24 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-03-10 | 2020-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-10 | 2020-04-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-03-10 | 2020-04-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-03-10 | 2020-04-24 | N |
| Provide activities to meet all resident's needs. | Health | 2020-03-10 | 2020-04-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-03-26 | 2019-04-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-26 | 2019-04-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-05 | 2019-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-05 | 2019-04-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-05 | 2019-04-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-05 | 2019-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-05 | 2019-04-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-05 | 2019-04-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-26 | 2019-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-26 | 2019-04-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-26 | 2019-04-01 | 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 | 2019-03-26 | 2019-03-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-11-08 | 2017-12-18 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2017-11-08 | 2017-12-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-11-08 | 2017-12-18 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2017-11-08 | 2017-12-18 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-12 | 2017-12-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-12 | 2017-12-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-11-08 | 2017-11-28 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-10-12 | 2017-11-12 | N |
