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Deficiency Records for Bailey-Boushay House
A list of the most recent deficiencies for Bailey-Boushay House. 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 Bailey-Boushay House. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-05-15 | 2024-07-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-20 | 2024-06-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-20 | 2024-06-24 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-20 | 2024-06-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-20 | 2024-06-24 | 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 | 2024-05-20 | 2024-06-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-05-20 | 2024-06-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-05-20 | 2024-06-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-20 | 2024-06-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-20 | 2024-06-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-20 | 2024-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-20 | 2024-06-24 | 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 | 2024-05-20 | 2024-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-20 | 2024-06-24 | 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 | 2024-05-20 | 2024-06-24 | 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 | 2024-05-20 | 2024-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-20 | 2024-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-20 | 2024-06-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-20 | 2024-06-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-23 | 2023-05-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-23 | 2023-04-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-23 | 2023-04-25 | N |
| Develop a communication plan. | Fire Safety | 2023-02-23 | 2023-04-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-01 | 2023-04-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-01 | 2023-04-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-03-01 | 2023-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-01 | 2023-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-01 | 2023-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-01 | 2023-04-14 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-03-01 | 2023-04-14 | 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 | 2023-03-01 | 2023-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-01 | 2023-04-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-01 | 2023-04-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-01 | 2023-04-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-23 | 2023-03-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-12 | 2023-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-04 | 2022-10-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-09 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-09 | 2022-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-06-14 | 2019-07-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-14 | 2019-07-19 | 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 | 2019-06-14 | 2019-07-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-12 | 2019-07-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-12 | 2019-07-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-12 | 2019-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-12 | 2019-07-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-12 | 2019-07-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-06-12 | 2019-07-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-12 | 2019-07-05 | N |
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