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Deficiency Records for Big Bend Woods Healthcare Center
A list of the most recent deficiencies for Big Bend Woods 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 Big Bend Woods 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? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-02-08 | 2024-03-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-08 | 2024-03-27 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-02-08 | 2024-03-16 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-02-08 | 2024-03-16 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-08 | 2024-03-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-08 | 2024-03-16 | N |
| 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 | 2024-02-08 | 2024-03-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-02-08 | 2024-03-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-08 | 2024-03-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-08 | 2024-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-08 | 2024-03-16 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-08 | 2024-03-16 | 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 | 2024-02-08 | 2024-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-03-16 | 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 | 2024-02-08 | 2024-03-16 | 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 | 2024-02-08 | 2024-03-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-08 | 2024-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-08 | 2024-03-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-08 | 2024-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | 2024-03-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-08 | 2024-03-16 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-06 | 2023-12-22 | Y |
| 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 | 2023-07-29 | 2023-08-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-21 | 2023-08-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-21 | 2023-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-21 | 2023-08-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-21 | 2023-08-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-21 | 2023-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-21 | 2023-08-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-25 | 2023-08-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-25 | 2023-08-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-25 | 2023-08-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-25 | 2023-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-08-11 | Y |
| 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 | 2023-05-25 | 2023-07-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-25 | 2023-06-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-25 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-06-30 | 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 | 2023-05-25 | 2023-06-30 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-25 | 2023-06-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-15 | 2022-11-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-09 | 2022-10-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-09 | 2022-10-19 | 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 | 2022-09-09 | 2022-10-19 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-09-09 | 2022-10-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-09 | 2022-10-19 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-09-09 | 2022-10-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-09 | 2022-08-29 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-08-09 | 2022-08-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-09 | 2022-08-29 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-08-09 | 2022-08-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-10 | 2022-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-24 | 2021-07-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-24 | 2021-07-20 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-05-24 | 2021-07-03 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-05-24 | 2021-07-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-24 | 2021-07-03 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-24 | 2021-07-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-05-24 | 2021-07-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-24 | 2021-07-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-24 | 2021-07-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-24 | 2021-07-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-24 | 2021-07-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-24 | 2021-07-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-07-03 | 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 | 2021-05-24 | 2021-07-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-24 | 2021-07-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-24 | 2021-07-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-24 | 2021-07-03 | 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 | 2021-05-24 | 2021-07-03 | 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 | 2021-05-24 | 2021-07-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-24 | 2021-07-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-24 | 2021-07-03 | 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 | 2021-05-24 | 2021-07-03 | 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 | 2021-05-24 | 2021-07-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-24 | 2021-07-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-24 | 2021-07-03 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-05-24 | 2021-07-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-24 | 2021-07-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-24 | 2021-07-03 | 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 | 2021-05-24 | 2021-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-24 | 2021-07-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-24 | 2021-07-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-24 | 2021-07-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-04 | 2019-07-18 | 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 | 2019-06-04 | 2019-07-18 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-06-04 | 2019-07-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-04 | 2019-07-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-04 | 2019-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-04 | 2019-07-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-04 | 2019-07-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-04 | 2019-07-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-04 | 2019-07-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-04 | 2019-07-18 | 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 | 2019-06-04 | 2019-07-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-06-04 | 2019-07-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-04 | 2019-07-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-04 | 2019-07-18 | 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 | 2019-06-04 | 2019-07-18 | 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 | 2019-06-04 | 2019-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-04 | 2019-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-04 | 2019-07-18 | N |
| Meet other general requirements. | Fire Safety | 2019-06-04 | 2019-07-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-04 | 2019-07-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-04 | 2019-07-18 | 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 | 2019-06-04 | 2019-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-04 | 2019-07-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-04 | 2019-07-18 | N |
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