Deficiency Records for Avamere Rehabilitation of Shoreline

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Updated as of March 01, 2024

A list of the most recent deficiencies for Avamere Rehabilitation of Shoreline. 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?
Respond appropriately to all alleged violations. Health 2023-09-20 2023-10-04 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-07-28 2023-08-28 Y
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 2022-12-20 2023-03-17 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-20 2023-03-17 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-12-20 2023-03-17 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2022-12-20 2023-03-17 N
Provide properly protected cooking facilities. Fire Safety 2022-12-20 2023-03-08 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-12-20 2023-02-24 N
Develop a communication plan. Fire Safety 2022-12-20 2023-02-20 N
Provide emergency officials' contact information. Fire Safety 2022-12-20 2023-02-20 N
Conduct testing and exercise requirements. Fire Safety 2022-12-20 2023-02-20 N
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2022-12-20 2023-02-10 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2022-12-22 2023-02-07 N
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2022-12-22 2023-02-03 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2022-12-20 2023-01-24 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-12-22 2023-01-20 N
Provide and implement an infection prevention and control program. Health 2022-12-22 2023-01-20 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-12-20 2023-01-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-12-20 2023-01-20 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-12-22 2023-01-19 N
Respond appropriately to all alleged violations. Health 2022-12-22 2023-01-19 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-12-22 2023-01-19 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2022-12-22 2023-01-19 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-12-22 2023-01-19 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-12-22 2023-01-19 N
Provide enough food/fluids to maintain a resident's health. Health 2022-12-22 2023-01-19 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-12-22 2023-01-19 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2022-12-22 2023-01-19 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2022-12-22 2023-01-19 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-12-22 2023-01-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-12-22 2023-01-19 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-12-20 2023-01-12 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2022-12-20 2023-01-05 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-12-20 2023-01-02 N
Meet other general requirements. Fire Safety 2022-12-20 2022-12-26 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-09-19 2022-10-21 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-09-19 2022-10-21 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-09-19 2022-10-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-27 2022-07-20 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-02-11 2022-03-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-02-11 2022-03-04 Y
Provide and implement an infection prevention and control program. Health 2022-01-24 2022-02-11 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2021-08-09 2021-09-29 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-08-09 2021-09-29 Y
Respond appropriately to all alleged violations. Health 2021-08-09 2021-09-29 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2021-08-09 2021-09-15 Y
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. Health 2021-05-28 2021-07-06 Y
Respond appropriately to all alleged violations. Health 2021-05-28 2021-07-06 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 2021-05-28 2021-07-06 Y
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 2019-10-31 2019-11-28 N
Provide properly protected cooking facilities. Fire Safety 2019-10-31 2019-11-28 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2019-11-08 2019-11-25 N
Ensure each resident receives an accurate assessment. Health 2019-11-08 2019-11-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-11-08 2019-11-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-11-08 2019-11-25 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2019-11-08 2019-11-25 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 2019-11-08 2019-11-25 N
Provide or obtain dental services for each resident. Health 2019-11-08 2019-11-25 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-11-08 2019-11-25 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2019-11-08 2019-11-25 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-10-31 2019-11-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-10-31 2019-11-14 N
Meet other general requirements. Fire Safety 2018-10-03 2018-12-14 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-10-03 2018-12-14 N
Address subsistence needs for staff and patients. Fire Safety 2018-10-03 2018-10-26 N
Establish policies and procedures for volunteers. Fire Safety 2018-10-03 2018-10-26 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2018-10-03 2018-10-26 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-10-03 2018-10-26 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2018-10-03 2018-10-26 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2018-10-03 2018-10-26 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2018-10-03 2018-10-26 N
Ensure proper usage of power strips and extension cords. Fire Safety 2018-10-03 2018-10-26 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2018-10-03 2018-10-26 N
Provide properly protected cooking facilities. Fire Safety 2018-10-03 2018-10-18 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2018-10-03 2018-10-05 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2018-10-03 2018-10-03 N
Establish roles under a Waiver declared by secretary. Fire Safety 2018-10-03 2018-10-03 N
Implement emergency and standby power systems. Fire Safety 2018-10-03 2018-10-03 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 2018-10-03 2018-10-03 N
Provide a written emergency evacuation plan. Fire Safety 2018-10-03 2018-10-03 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2018-08-27 2018-09-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-08-27 2018-09-28 N