A list of the most recent deficiencies for The Shores Post-Acute. 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 testing and exercise requirements. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Use approved construction type or materials. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-25 | 2024-02-27 | 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 | 2024-01-25 | 2024-02-27 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-25 | 2024-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-11 | 2024-02-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-11 | 2024-02-12 | 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 and emergencies. | Health | 2024-01-11 | 2024-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-11 | 2024-02-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-30 | 2023-09-14 | Y |
| 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 | 2023-08-11 | 2023-08-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-08 | 2023-03-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-10 | 2022-06-24 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-05-11 | 2022-06-15 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-22 | 2022-06-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-22 | 2022-06-13 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-22 | 2022-06-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-22 | 2022-06-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-22 | 2022-05-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-22 | 2022-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-22 | 2022-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-22 | 2022-05-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-22 | 2022-05-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-22 | 2022-05-05 | 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 | 2022-02-22 | 2022-05-05 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-02-22 | 2022-05-05 | 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 | 2022-02-22 | 2022-05-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-22 | 2022-05-05 | 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 | 2022-02-22 | 2022-05-05 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-02-22 | 2022-05-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-22 | 2022-05-05 | 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 | 2022-02-22 | 2022-05-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-22 | 2022-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-05-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-22 | 2022-05-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-22 | 2022-05-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-22 | 2022-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-09 | 2022-03-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-15 | 2022-03-07 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-24 | 2022-02-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-01-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-18 | 2022-01-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-10 | 2022-01-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-14 | 2021-12-21 | 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 | 2019-10-23 | 2019-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-23 | 2019-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-23 | 2019-11-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-23 | 2019-11-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-30 | 2019-11-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-30 | 2019-11-13 | 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 | 2019-09-30 | 2019-11-13 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-09-30 | 2019-11-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-30 | 2019-11-13 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-30 | 2019-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-30 | 2019-11-13 | 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 | 2019-09-30 | 2019-11-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-30 | 2019-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-30 | 2019-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-30 | 2019-11-13 | 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 | 2019-09-30 | 2019-11-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-30 | 2019-11-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-30 | 2019-11-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-30 | 2019-11-13 | N |
| 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 | 2019-09-30 | 2019-11-13 | 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 | 2019-09-30 | 2019-11-13 | N |
| Provide or obtain dental services for each resident. | Health | 2019-09-30 | 2019-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-30 | 2019-11-13 | 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 and emergencies. | Health | 2019-09-30 | 2019-11-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-30 | 2019-11-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-09-30 | 2019-11-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-30 | 2019-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-30 | 2019-11-13 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-30 | 2019-11-13 | N |
