A list of the most recent deficiencies for Complete Care at Bayshore LLC. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-14 | 2024-03-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-19 | 2023-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-19 | 2023-11-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-19 | 2023-11-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-19 | 2023-11-17 | 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 | 2023-10-19 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-19 | 2023-11-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-19 | 2023-11-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-19 | 2023-11-17 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-19 | 2023-11-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-19 | 2023-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-19 | 2023-11-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-19 | 2023-11-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-03 | 2022-10-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-03 | 2022-10-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-10-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-03 | 2022-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-10-03 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-08-03 | 2022-09-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-03 | 2022-09-13 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-03 | 2022-09-13 | 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 | 2022-08-03 | 2022-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-03 | 2022-09-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-03 | 2022-09-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-03 | 2022-09-13 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-03 | 2022-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-03 | 2022-09-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-03 | 2022-09-13 | 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 | 2022-08-03 | 2022-09-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-03 | 2022-09-13 | 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 | 2022-08-03 | 2022-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-03 | 2022-09-13 | 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 | 2022-08-03 | 2022-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-03 | 2022-09-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-03 | 2022-09-13 | 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 | 2022-08-03 | 2022-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-03 | 2022-09-13 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-08-03 | 2022-09-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-03 | 2022-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-27 | 2020-03-06 | N |
