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Deficiency Records for Bay Vista Healthcare and Wellness Centre, LP

A list of the most recent deficiencies for Bay Vista Healthcare and Wellness Centre, LP. 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 Bay Vista Healthcare and Wellness Centre, LP. 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?
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-06-30 2024-07-25 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-06-30 2024-07-25 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-06-30 2024-07-25 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-06-30 2024-07-25 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 2024-06-30 2024-07-25 N
Ensure medication error rates are not 5 percent or greater. Health 2024-06-30 2024-07-25 N
Provide routine and 24-hour emergency dental care for each resident. Health 2024-06-30 2024-07-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-30 2024-07-25 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2024-06-30 2024-07-25 N
Provide and implement an infection prevention and control program. Health 2024-06-30 2024-07-25 N
Keep all essential equipment working safely. Health 2024-06-30 2024-07-25 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2024-06-30 2024-07-25 Y
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2024-07-01 2024-07-25 N
Install an approved automatic sprinkler system. Fire Safety 2024-07-01 2024-07-25 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-05-13 2024-06-10 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-12-12 2024-01-11 Y
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-09-15 2023-10-13 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2023-09-15 2023-10-13 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-07 2023-09-08 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 2023-04-06 2023-04-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-01-19 2023-02-03 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-10-28 2022-11-25 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-09-13 2022-10-21 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-09-13 2022-10-21 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-09-13 2022-10-21 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-09-13 2022-10-21 Y
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 2022-09-13 2022-10-21 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 2022-08-29 2022-09-12 Y
Provide and implement an infection prevention and control program. Health 2022-08-16 2022-09-06 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-12-14 2021-12-27 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-10 2021-12-21 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-07-19 2021-08-18 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-07-19 2021-08-18 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-07-19 2021-08-18 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2021-07-19 2021-08-18 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2021-07-19 2021-08-18 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-07-19 2021-08-18 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-07-19 2021-08-18 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-07-19 2021-08-18 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-07-19 2021-08-18 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-07-19 2021-08-18 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2021-07-19 2021-08-18 N
Ensure medication error rates are not 5 percent or greater. Health 2021-07-19 2021-08-18 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 2021-07-19 2021-08-18 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 2021-07-19 2021-08-18 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-07-19 2021-08-18 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-07-19 2021-08-18 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2021-07-19 2021-08-18 N
Provide and implement an infection prevention and control program. Health 2021-07-19 2021-08-18 N
Keep all essential equipment working safely. Health 2021-07-19 2021-08-18 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2021-07-19 2021-08-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-12-23 2020-01-30 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2019-12-23 2020-01-30 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2019-12-23 2020-01-30 N
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2019-12-23 2020-01-30 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2019-12-23 2020-01-30 N
Ensure each resident receives an accurate assessment. Health 2019-12-23 2020-01-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-12-23 2020-01-30 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-12-23 2020-01-30 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 2019-12-23 2020-01-30 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-12-23 2020-01-30 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2019-12-23 2020-01-30 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2019-12-23 2020-01-30 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 2019-12-23 2020-01-30 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-12-23 2020-01-30 N
Provide and implement an infection prevention and control program. Health 2019-12-23 2020-01-30 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2019-12-23 2020-01-30 N
Conduct testing and exercise requirements. Fire Safety 2019-12-19 2020-01-16 N
Provide properly protected cooking facilities. Fire Safety 2019-12-19 2020-01-16 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2019-12-19 2020-01-16 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-12-19 2020-01-16 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-12-19 2020-01-16 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-12-19 2020-01-16 N

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