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Deficiency Records for Hudson Bay Health and Rehabilitation

A list of the most recent deficiencies for Hudson Bay Health and Rehabilitation. 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 Hudson Bay Health and Rehabilitation. 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?
Include a process for Emergency Preparedness collaboration. Fire Safety 2024-06-05 2024-07-09 N
Establish policies and procedures including evacuation. Fire Safety 2024-06-05 2024-07-09 N
Develop a communication plan. Fire Safety 2024-06-05 2024-07-09 N
List the names and contact information of those in the facility. Fire Safety 2024-06-05 2024-07-09 N
Provide primary/alternate means for communication. Fire Safety 2024-06-05 2024-07-09 N
Provide family notifications of emergency plan. Fire Safety 2024-06-05 2024-07-09 N
Establish emergency prep training and testing. Fire Safety 2024-06-05 2024-07-09 N
Conduct testing and exercise requirements. Fire Safety 2024-06-05 2024-07-09 N
Meet other general requirements. Fire Safety 2024-06-05 2024-07-09 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 2024-06-05 2024-07-09 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-06-05 2024-07-09 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-06-05 2024-07-09 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-06-07 2024-06-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-07 2024-06-28 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-06-07 2024-06-28 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-06-07 2024-06-28 Y
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Health 2023-09-22 2023-10-20 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-05-08 2023-06-05 N
The resident has the right to receive notices in a format and a language he or she understands. Health 2023-05-08 2023-06-05 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2023-05-08 2023-06-05 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 2023-05-08 2023-06-05 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 2023-05-08 2023-06-05 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 2023-05-08 2023-06-05 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 2023-05-08 2023-06-05 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 2023-05-08 2023-06-05 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 2023-05-08 2023-06-05 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2023-05-08 2023-06-05 N
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Health 2023-05-08 2023-06-05 N
Provide a neutral and fair arbitration process and agree to arbitrator and venue. Health 2023-05-08 2023-06-05 N
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. Health 2023-05-08 2023-06-05 Y
Address patient/client population and determine types of services needed. Fire Safety 2023-05-08 2023-06-05 N
Address subsistence needs for staff and patients. Fire Safety 2023-05-08 2023-06-05 N
Establish policies and procedures including evacuation. Fire Safety 2023-05-08 2023-06-05 N
Establish policies and procedures for sheltering. Fire Safety 2023-05-08 2023-06-05 N
Provide primary/alternate means for communication. Fire Safety 2023-05-08 2023-06-05 N
Provide family notifications of emergency plan. Fire Safety 2023-05-08 2023-06-05 N
Establish emergency prep training and testing. Fire Safety 2023-05-08 2023-06-05 N
Establish staff and initial training requirements. Fire Safety 2023-05-08 2023-06-05 N
Conduct testing and exercise requirements. Fire Safety 2023-05-08 2023-06-05 N
Provide properly protected cooking facilities. Fire Safety 2023-05-08 2023-06-05 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-05-08 2023-06-05 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-05-08 2023-06-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-05-08 2023-06-05 N
Ensure medical gas and vacuum systems have documented maintenance programs. Fire Safety 2023-05-08 2023-06-05 N
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. Fire Safety 2023-05-08 2023-06-05 N
Have proper power supply for life support equipment. Fire Safety 2023-05-08 2023-06-05 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2023-05-08 2023-06-05 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-05-08 2023-06-05 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-05-08 2023-06-05 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2023-05-08 2023-06-05 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-09-29 2022-10-28 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-03-01 2022-04-01 Y
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 2022-02-22 2022-04-01 N
Keep residents' personal and medical records private and confidential. Health 2022-02-22 2022-04-01 N
Ensure each resident receives an accurate assessment. Health 2022-02-22 2022-04-01 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-02-22 2022-04-01 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 2022-02-22 2022-04-01 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-02-22 2022-04-01 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-02-22 2022-04-01 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 2022-02-22 2022-04-01 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 2022-02-22 2022-04-01 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-02-22 2022-04-01 N
Provide and implement an infection prevention and control program. Health 2022-02-22 2022-04-01 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-02-22 2022-04-01 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 2022-02-22 2022-04-01 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-02-15 2022-03-18 N
Establish staff and initial training requirements. Fire Safety 2022-02-15 2022-03-18 N
Conduct testing and exercise requirements. Fire Safety 2022-02-15 2022-03-18 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 2022-02-15 2022-03-18 N

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