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Deficiency Records for Bywood East Health Care
A list of the most recent deficiencies for Bywood East Health Care. 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 Bywood East Health Care. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-26 | 2024-07-17 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-04 | 2024-06-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-04 | 2024-05-24 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-03-04 | 2024-05-13 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-04-11 | 2024-05-10 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-04-11 | 2024-05-10 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-03-04 | 2024-05-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-04 | 2024-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-04 | 2024-05-08 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-03-07 | 2024-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-07 | 2024-04-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-07 | 2024-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-07 | 2024-04-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-07 | 2024-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-04-29 | 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 | 2024-03-07 | 2024-04-29 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-03-07 | 2024-04-29 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-03-07 | 2024-04-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-07 | 2024-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-04-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-03-07 | 2024-04-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-03-07 | 2024-04-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-03-07 | 2024-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-04 | 2024-03-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-04 | 2024-03-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-04 | 2024-03-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-03-07 | 2024-03-14 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-07 | 2024-03-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-03-04 | 2024-03-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-04 | 2024-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-04 | 2024-03-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-04 | 2024-03-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-22 | 2024-02-26 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-22 | 2024-02-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-22 | 2024-02-26 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-31 | 2023-09-23 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-08-31 | 2023-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-08-31 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-22 | 2023-03-10 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-12-22 | 2023-03-07 | N |
| Have an externally vented heating system. | Fire Safety | 2022-12-21 | 2023-02-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-22 | 2023-02-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-22 | 2023-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-02-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-22 | 2023-02-10 | 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 | 2022-12-22 | 2023-02-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-22 | 2023-02-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-22 | 2023-02-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-22 | 2023-02-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-22 | 2023-02-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-21 | 2023-02-10 | 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 | 2022-12-21 | 2023-02-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-10 | 2022-11-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-10 | 2022-11-11 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-10 | 2022-11-11 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-10-10 | 2022-11-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-10 | 2022-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-07 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-07 | 2022-03-18 | Y |
| Report COVID19 data to residents and families. | Health | 2022-02-07 | 2022-03-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-07 | 2022-03-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-12 | 2021-09-29 | 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 | 2021-08-12 | 2021-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide or obtain dental services for each resident. | Health | 2021-08-12 | 2021-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-12 | 2021-09-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-12 | 2021-09-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
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