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Deficiency Records for Fort Bayard Medical Center
A list of the most recent deficiencies for Fort Bayard Medical 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 Fort Bayard Medical 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-09 | 2024-09-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-08-09 | 2024-09-23 | 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 | 2024-08-09 | 2024-09-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-08-09 | 2024-09-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-09 | 2024-09-23 | 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 | 2024-08-09 | 2024-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-09 | 2024-09-23 | 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 | 2024-08-09 | 2024-09-23 | N |
| Post nurse staffing information every day. | Health | 2024-08-09 | 2024-09-23 | 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 | 2024-08-09 | 2024-09-23 | 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 | 2024-08-09 | 2024-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-09 | 2024-09-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-06 | 2024-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-06 | 2024-09-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-08-06 | 2024-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-06 | 2024-09-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-06-11 | 2024-07-26 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-06-11 | 2024-07-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-11 | 2024-07-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-11 | 2024-07-26 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-06-11 | 2024-07-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-01 | 2023-09-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-01 | 2023-09-08 | 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 | 2023-06-01 | 2023-09-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-01 | 2023-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-01 | 2023-09-08 | 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 | 2023-06-01 | 2023-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-01 | 2023-09-08 | 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 | 2023-06-01 | 2023-09-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-01 | 2023-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-01 | 2023-09-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-01 | 2023-09-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-01 | 2023-09-08 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-01 | 2023-09-08 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-24 | 2023-09-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-03 | 2022-04-30 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-03-03 | 2022-04-30 | 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 | 2022-03-03 | 2022-04-30 | 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 | 2022-03-03 | 2022-04-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-03-03 | 2022-04-30 | 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 | 2022-03-03 | 2022-04-30 | 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 | 2022-03-03 | 2022-04-30 | N |
| Provide or obtain dental services for each resident. | Health | 2022-03-03 | 2022-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-04-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-03 | 2022-04-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-03 | 2022-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-03 | 2022-04-30 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-03 | 2022-04-30 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-03-03 | 2022-04-30 | N |
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