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Deficiency Records for Bay Harbor Post Acute Healthcare Center
A list of the most recent deficiencies for Bay Harbor Post Acute Healthcare Center. 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 Harbor Post Acute Healthcare Center. 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? |
|---|---|---|---|---|
| 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 | 2024-02-28 | 2024-05-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-28 | 2024-05-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-28 | 2024-05-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-28 | 2024-04-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-28 | 2024-04-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-28 | 2024-04-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-28 | 2024-04-11 | 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 | 2024-02-28 | 2024-04-11 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-02-28 | 2024-04-11 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-28 | 2024-04-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-28 | 2024-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-28 | 2024-04-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-28 | 2024-04-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-04-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-28 | 2024-04-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-28 | 2024-04-11 | Y |
| Keep all essential equipment working safely. | Health | 2024-02-28 | 2024-04-11 | Y |
| 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 | 2019-12-06 | 2020-01-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-06 | 2020-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-06 | 2020-01-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-06 | 2020-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-06 | 2020-01-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-06 | 2020-01-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-12-06 | 2020-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-06 | 2020-01-20 | 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 | 2019-10-16 | 2019-11-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-16 | 2019-11-28 | 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 | 2019-10-16 | 2019-11-28 | N |
| 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 | 2019-10-16 | 2019-11-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-16 | 2019-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-16 | 2019-11-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-16 | 2019-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-11-28 | N |
| Keep all essential equipment working safely. | Health | 2019-10-16 | 2019-11-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-18 | 2018-07-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-18 | 2018-07-31 | 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 | 2018-06-18 | 2018-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-18 | 2018-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-18 | 2018-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-18 | 2018-07-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-18 | 2018-07-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-06-18 | 2018-07-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-11 | 2018-07-25 | 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 | 2018-05-11 | 2018-06-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-05-11 | 2018-06-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-05-11 | 2018-06-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-11 | 2018-06-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-05-11 | 2018-06-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-03-16 | 2017-05-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-03-16 | 2017-05-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-03-16 | 2017-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-16 | 2017-05-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-21 | 2017-05-02 | N |
| Let residents choose whether to manage their own money or deposit it with the nursing home. | Health | 2017-03-21 | 2017-05-02 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-21 | 2017-05-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-21 | 2017-05-02 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-21 | 2017-05-02 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-03-21 | 2017-05-02 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-21 | 2017-05-02 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-21 | 2017-05-02 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-21 | 2017-05-02 | N |
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