A list of the most recent deficiencies for Southshore Health Care Center. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-08 | 2023-04-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-08 | 2023-04-14 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-03-02 | 2023-04-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-02 | 2023-04-10 | 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 | 2023-03-02 | 2023-04-10 | 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 | 2023-03-02 | 2023-04-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-02 | 2023-04-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-02 | 2023-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-04-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-02 | 2023-04-10 | 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 | 2023-03-02 | 2023-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-02 | 2023-04-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-02 | 2023-04-10 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-03-02 | 2023-04-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-02 | 2023-04-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-10 | 2022-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-10 | 2022-02-28 | 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 | 2019-12-09 | 2020-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-09 | 2020-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-09 | 2020-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-09 | 2020-01-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-01 | 2019-11-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-10-01 | 2019-11-29 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-10-01 | 2019-11-29 | 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 | 2019-10-01 | 2019-11-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-01 | 2019-11-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-01 | 2019-11-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-01 | 2019-11-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-01 | 2019-11-29 | 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 | 2019-10-01 | 2019-11-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-01 | 2019-11-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-01 | 2019-11-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-01 | 2019-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-14 | 2018-09-21 | N |
| 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 | 2018-08-14 | 2018-09-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-14 | 2018-09-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-08-14 | 2018-09-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-14 | 2018-09-21 | 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 | 2018-08-14 | 2018-09-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-08-14 | 2018-09-21 | N |
