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Deficiency Records for Bayside Village
A list of the most recent deficiencies for Bayside Village. 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 Bayside Village. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2024-07-15 | 2024-08-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-15 | 2024-08-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-15 | 2024-08-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-15 | 2024-08-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-15 | 2024-08-17 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-07-11 | 2024-08-10 | 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 | 2024-07-11 | 2024-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-11 | 2024-08-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-07-11 | 2024-08-10 | 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 | 2024-07-11 | 2024-08-10 | 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 | 2024-07-11 | 2024-08-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-11 | 2024-08-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-11 | 2024-08-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-11 | 2024-08-10 | 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 | 2024-07-11 | 2024-08-10 | 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 | 2024-07-11 | 2024-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-11 | 2024-08-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-07-11 | 2024-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-11 | 2024-08-10 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-07-11 | 2024-08-10 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-07-11 | 2024-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-22 | 2024-05-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-17 | 2023-08-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-17 | 2023-08-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-17 | 2023-08-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-17 | 2023-08-15 | 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 | 2023-07-17 | 2023-08-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-17 | 2023-08-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-17 | 2023-08-15 | 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 | 2023-07-17 | 2023-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-17 | 2023-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-17 | 2023-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-07-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-27 | 2023-01-06 | 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 | 2022-09-27 | 2023-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-27 | 2023-01-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2023-01-06 | 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 | 2022-09-27 | 2022-12-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-21 | 2022-12-10 | N |
| Post nurse staffing information every day. | Health | 2022-09-27 | 2022-12-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-27 | 2022-12-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-21 | 2022-11-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-21 | 2022-10-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-27 | 2022-10-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-27 | 2022-10-29 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-27 | 2022-10-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-27 | 2022-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-27 | 2022-10-29 | 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 | 2022-09-27 | 2022-10-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-27 | 2022-10-29 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-27 | 2022-10-29 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-09-27 | 2022-10-29 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2022-09-27 | 2022-10-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-27 | 2022-10-29 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-27 | 2022-10-29 | 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 | 2022-09-27 | 2022-10-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-27 | 2022-10-29 | 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 | 2022-09-27 | 2022-10-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-27 | 2022-10-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-27 | 2022-10-29 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-27 | 2022-10-29 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-27 | 2022-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-14 | 2022-09-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-03 | 2022-05-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-03 | 2022-05-13 | Y |
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