Deficiency Records for The Villages of General Baptist Health Care West
Updated as of April 01, 2024
A list of the most recent deficiencies for The Villages of General Baptist Health Care West. 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 manage his or her financial affairs. | Health | 2023-12-01 | 2024-01-01 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-12-01 | 2024-01-01 | 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 | 2023-12-01 | 2024-01-01 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-01 | 2024-01-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2024-01-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2024-01-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-01 | 2024-01-01 | 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 | 2023-12-01 | 2024-01-01 | 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 | 2023-12-01 | 2024-01-01 | 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 | 2023-12-01 | 2024-01-01 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-12-01 | 2024-01-01 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-12-01 | 2024-01-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2024-01-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-01 | 2024-01-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-01 | 2024-01-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-01 | 2024-01-01 | 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 | 2023-12-01 | 2024-01-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-01 | 2024-01-01 | 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 | 2023-12-01 | 2024-01-01 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-11-29 | 2024-01-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-07 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-09-02 | 2022-10-02 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-09-02 | 2022-10-02 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-02 | 2022-10-02 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-09-02 | 2022-10-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | 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 | 2022-09-02 | 2022-10-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-10-02 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-09-02 | 2022-10-02 | N |
| Report COVID19 data to residents and families. | Health | 2022-09-02 | 2022-10-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-30 | 2022-10-02 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-08-30 | 2022-10-02 | 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 | 2022-08-16 | 2022-09-15 | Y |
| Keep all essential equipment working safely. | Health | 2022-08-16 | 2022-09-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-16 | 2022-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-09 | 2022-07-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-09 | 2022-07-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-09 | 2022-07-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-27 | 2021-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-27 | 2021-10-27 | Y |
| 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 | 2021-09-27 | 2021-10-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-28 | 2021-06-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-28 | 2021-06-25 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-05-28 | 2021-06-25 | 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 | 2021-05-28 | 2021-06-25 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-05-28 | 2021-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-28 | 2021-06-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-28 | 2021-06-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-28 | 2021-06-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-28 | 2021-06-25 | N |
| Provide appropriate foot care. | Health | 2021-05-28 | 2021-06-25 | 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 | 2021-05-28 | 2021-06-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-28 | 2021-06-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-28 | 2021-06-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-28 | 2021-06-25 | 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 | 2021-05-28 | 2021-06-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-05-28 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-28 | 2021-06-25 | Y |
