A list of the most recent deficiencies for Baypoint Healthcare 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-12 | 2023-07-17 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-31 | 2023-03-08 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-31 | 2023-03-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-31 | 2023-03-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-01 | 2022-11-18 | 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 | 2022-09-19 | 2022-10-05 | Y |
| 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 | 2022-08-26 | 2022-09-19 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-08-26 | 2022-09-19 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-26 | 2022-09-19 | 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 | 2022-05-09 | 2022-06-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-16 | 2022-05-19 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-24 | 2022-04-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-24 | 2022-04-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-24 | 2022-04-24 | 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 | 2022-03-24 | 2022-04-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-24 | 2022-04-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-24 | 2022-04-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-04-24 | 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 | 2022-03-24 | 2022-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-24 | 2022-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-24 | 2022-04-24 | 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 | 2022-03-24 | 2022-04-24 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-03-24 | 2022-04-24 | 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 | 2022-03-24 | 2022-04-24 | 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 | 2022-03-24 | 2022-04-24 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-03-24 | 2022-04-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-24 | 2022-04-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-24 | 2022-04-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-24 | 2022-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-24 | 2022-04-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-24 | 2022-04-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-30 | 2022-04-11 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-30 | 2022-04-11 | 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 | 2022-03-30 | 2022-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-30 | 2022-04-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-30 | 2022-04-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-30 | 2022-04-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-20 | 2019-09-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-11 | 2019-08-13 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-07-11 | 2019-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-11 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-07-11 | 2019-08-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-29 | 2018-09-14 | 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 | 2018-08-29 | 2018-09-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-29 | 2018-09-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-21 | 2018-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-21 | 2018-07-20 | 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 | 2018-06-21 | 2018-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-21 | 2018-07-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-06-21 | 2018-07-20 | 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 | 2018-06-21 | 2018-07-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-21 | 2018-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-26 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-12 | Not Fixed | 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 | 2021-10-12 | Not Fixed | N |
