North Shore Health & Rehab Facility

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

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.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility' s general characteristics. The survey was conducted under the regulatory requirements of 42 CFR Part 483.70(a)The facility is one story, Type V (000) construction and is protected by an automatic fire sprinkler system. The facility is classified as Fully Sprinklered. The 120 bed facility was surveyed on June 13, 2024 using the National Fire Protection Association, (NFPA) Life Safety Code (2012) Chapter 19, Existing Health Care Occupancies. Life safety features that met the requirements for new construction at the time of licensure or certification shall be maintained and not diminished. The deficiencies cited were discussed with Maintenance staff during the exit conference conducted at the end of the on-site survey. The reported daily census to be 80 residents on the day of the survey. Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by the following:1. Fire sprinkler gauge is outdated in the fire sprinkler riser room (2018).2. Missing fire sprinkler escutcheon plate in the main lobby.3. A 5-year fire sprinkler internal obstruction testing report was not provided for the wet system.5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.NFPA 25, 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection.NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance Director during the exit conference.

A recertification survey was conducted from 5/13/24 to 5/16/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 5/13/24 to 5/16/24. No deficiencies were cited. Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one of three units. Specifically, the facility failed to:-Follow proper infection control processes for cleaning and disinfecting lifts and vital signs equipment on the Parkview unit; and,-Use proper infectio.. Based on observations, interventions and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically the facility failed to:-Ensure the high temperature dish washing machine functioned at the proper temperatures for one of two facility dish washing machines;-Ensure, for a high temperature dish washing machine, an irreversible registering surface temperature indicator (test strip) was present .. Based on observations, record review and interviews, the facility failed to assess, accurately document and provide treatment for one (#32) of four residents reviewed for pressure ulcers out of 31 sample residents.Specifically, the facility failed to:-Ensure the progress of Resident #32' s pressure ulcers was documented consistently and accurately;-Identify Resident #32 had a pressure wound which had reopened on her coccyx; and,-Obtain appropriate .. Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs.Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet order of level six soft and bite-sized texture as indicated on their meal tray cards.Findings include:I. Professional referenceThe International Dysphagia (d.. Based on observations, record review and interviews, the facility failed to ensure two (#32 and #1) of five residents reviewed for pain management out of 31 sample residents received timely, adequate pain control. Specifically, the facility failed to:-Ensure pain was effectively managed during incontinence care for Resident #32;-Ensure Resident #32 was provided as needed (PRN) pain medication prior to brief changes per physician' s orders;-Ensure staff consistently.. Based on record review, observations and interviews, the facility failed to ensure one (#1) of five residents reviewed for unnecessary medications out of 31 sample residents were free from unnecessary medications. Specifically the facility failed to: -Ensure Resident #1 had appropriate non-pharmacological interventions for behaviors initiated; -Ensure Resident #1 was monitored for side effects of a psychotropic medications; and, -Ensure Resident #1 was moni..