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Deficiency Records for The Shores of Worthington
A list of the most recent deficiencies for The Shores of Worthington. 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 The Shores of Worthington. 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? |
|---|---|---|---|---|
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2025-03-04 | 2025-05-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-03-04 | 2025-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-04 | 2025-05-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-03-04 | 2025-05-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-03-04 | 2025-05-14 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2025-03-04 | 2025-05-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-04 | 2025-05-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-04 | 2025-05-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-04 | 2025-05-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-03-04 | 2025-05-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-04-11 | 2025-05-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-04-11 | 2025-05-08 | Y |
| 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 | 2025-04-11 | 2025-05-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-04-11 | 2025-05-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-03-04 | 2025-04-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2025-03-04 | 2025-04-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2025-03-04 | 2025-04-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2025-03-04 | 2025-04-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-03-04 | 2025-04-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-03-04 | 2025-04-03 | 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 | 2025-03-04 | 2025-04-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-03-04 | 2025-04-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2025-03-04 | 2025-04-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2025-02-27 | 2025-04-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-03-04 | 2025-04-03 | N |
| 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 | 2025-03-04 | 2025-04-03 | 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 | 2025-03-04 | 2025-04-03 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2025-03-04 | 2025-04-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-03-04 | 2025-04-03 | 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 | 2025-03-04 | 2025-04-03 | 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 (including nights and weekends) and emergencies. | Health | 2025-03-04 | 2025-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-15 | 2025-02-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-12-12 | 2025-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-12-12 | 2025-01-06 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-12-12 | 2025-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-12-12 | 2025-01-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-12-12 | 2025-01-06 | Y |
| 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 | 2024-12-12 | 2025-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-29 | 2024-09-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-01 | 2024-05-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-01 | 2024-05-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-21 | 2024-01-28 | 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 | 2023-12-21 | 2024-01-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-21 | 2024-01-28 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-12-21 | 2024-01-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-21 | 2024-01-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-21 | 2024-01-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-21 | 2024-01-28 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-12-21 | 2024-01-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-21 | 2024-01-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-21 | 2024-01-28 | 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 | 2023-12-21 | 2024-01-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-21 | 2024-01-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-01-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-19 | 2024-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-05-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-29 | 2023-05-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-29 | 2023-05-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-27 | 2023-04-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-27 | 2023-04-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-05 | 2023-02-03 | Y |
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