A list of the most recent deficiencies for Bickford Health Care 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-14 | 2022-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-16 | 2022-05-26 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-16 | 2022-05-26 | 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 | 2022-03-16 | 2022-05-26 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-05-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-16 | 2022-05-20 | 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 | 2021-12-28 | 2022-03-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-28 | 2022-03-17 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-28 | 2022-03-17 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-12-28 | 2022-03-17 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-12-28 | 2022-03-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-12-28 | 2022-03-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-28 | 2022-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-28 | 2022-03-17 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-12-28 | 2022-03-17 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-12-28 | 2022-03-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-28 | 2022-03-17 | 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 | 2021-12-28 | 2022-03-17 | 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 | 2021-12-28 | 2022-03-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-12-28 | 2022-03-17 | 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 | 2021-12-28 | 2022-03-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-28 | 2022-03-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-28 | 2022-03-17 | 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 | 2021-12-28 | 2022-03-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-28 | 2022-03-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-28 | 2022-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-28 | 2022-03-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-28 | 2022-03-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-28 | 2022-03-17 | N |
| Report COVID19 data to residents and families. | Health | 2021-12-28 | 2022-03-17 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-28 | 2022-03-17 | 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 | 2021-12-28 | 2022-03-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-28 | 2022-03-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-22 | 2022-03-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-22 | 2022-03-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-22 | 2022-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-22 | 2022-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-11-27 | 2020-01-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-27 | 2020-01-07 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-11-26 | 2020-01-06 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-11-27 | 2020-01-06 | 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 | 2019-11-27 | 2020-01-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-27 | 2020-01-06 | 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 | 2019-11-26 | 2019-12-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-26 | 2019-12-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-26 | 2019-12-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2019-12-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-26 | 2019-12-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-27 | 2019-12-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-18 | 2019-02-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-12-18 | 2019-02-25 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-12-18 | 2019-02-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-18 | 2019-02-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-18 | 2019-02-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-20 | 2019-01-31 | 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 | 2018-12-20 | 2019-01-31 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-12-20 | 2019-01-31 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-12-20 | 2019-01-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-12-20 | 2019-01-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-20 | 2019-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-20 | 2019-01-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-20 | 2019-01-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-20 | 2019-01-31 | 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 | 2018-12-20 | 2019-01-31 | 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 | 2018-12-20 | 2019-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-20 | 2019-01-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-12-20 | 2019-01-31 | N |
