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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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-10 | 2024-10-03 | Y |
| 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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