A list of the most recent deficiencies for North Bay Post Acute. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-11 | 2023-10-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-11 | 2023-10-28 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-11 | 2023-10-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-23 | 2023-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-23 | 2023-04-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-23 | 2023-04-01 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-01-18 | 2023-03-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-01-18 | 2023-03-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-01-18 | 2023-03-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-01-18 | 2023-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-18 | 2023-03-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-18 | 2023-03-13 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-18 | 2023-03-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-18 | 2023-03-13 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-01-18 | 2023-03-13 | 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 | 2023-01-18 | 2023-03-13 | 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 | 2023-01-18 | 2023-03-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-18 | 2023-03-13 | 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 | 2023-01-18 | 2023-03-13 | 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 | 2023-01-18 | 2023-03-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-18 | 2023-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-03-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-18 | 2023-03-13 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-01-18 | 2023-03-13 | N |
| Have policies on smoking. | Health | 2023-01-18 | 2023-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-03-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-18 | 2023-03-13 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| 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 | 2023-01-24 | 2023-02-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-24 | 2023-02-17 | 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 | 2022-03-07 | 2022-03-16 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-06-28 | 2021-07-16 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Use approved construction type or materials. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-08-13 | 2020-09-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-03-13 | 2020-05-11 | 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 | 2020-03-13 | 2020-05-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-13 | 2020-05-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-13 | 2020-05-11 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-03-13 | 2020-05-11 | 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 | 2020-03-13 | 2020-05-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-13 | 2020-05-11 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2020-03-13 | 2020-05-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-13 | 2020-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-13 | 2020-05-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-13 | 2019-06-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-13 | 2019-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-13 | 2019-06-06 | 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 | 2019-03-13 | 2019-06-06 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-03-13 | 2019-06-06 | 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 | 2019-03-13 | 2019-06-06 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-03-13 | 2019-06-06 | 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 | 2019-03-13 | 2019-06-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-13 | 2019-06-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-03-13 | 2019-06-06 | 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 | 2019-03-13 | 2019-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-13 | 2019-06-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-13 | 2019-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-13 | 2019-06-06 | N |
| Keep all essential equipment working safely. | Health | 2019-03-13 | 2019-06-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-04-24 | 2019-05-13 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-24 | 2019-05-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-24 | 2019-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-24 | 2019-05-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-24 | 2019-05-13 | N |
