A list of the most recent deficiencies for Azure Shores Rehab. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-10 | 2023-10-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-08 | 2023-07-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-08 | 2023-07-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-08 | 2023-07-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-08 | 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 | 2023-06-08 | 2023-07-08 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-08 | 2023-07-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-08 | 2023-07-08 | N |
| Keep all essential equipment working safely. | Health | 2023-06-08 | 2023-07-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-07 | 2023-07-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-07 | 2023-07-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-04-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-04-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-06-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-28 | 2022-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-28 | 2022-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-28 | 2022-06-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-28 | 2022-06-20 | 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 | 2022-04-28 | 2022-06-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-28 | 2022-06-20 | N |
| Keep all essential equipment working safely. | Health | 2022-04-28 | 2022-06-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-28 | 2022-06-20 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-04-28 | 2022-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-06-20 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2022-04-28 | 2022-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-28 | 2022-06-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-28 | 2022-06-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-28 | 2021-09-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-28 | 2021-09-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-28 | 2021-09-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-13 | 2021-06-12 | Y |
| Keep all essential equipment working safely. | Health | 2021-03-10 | 2021-04-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-19 | 2020-01-19 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-12-19 | 2020-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-19 | 2020-01-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-19 | 2020-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-17 | 2020-01-19 | N |
