Deficiency Records for Bay Breeze Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Bay Breeze Health and Rehabilitation 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-10 | 2023-11-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-10 | 2023-11-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-10 | 2023-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-10 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-10 | 2023-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-05 | 2023-11-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-05 | 2023-11-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-05 | 2023-11-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-05 | 2023-11-05 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-05 | 2023-11-05 | 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 | 2023-10-05 | 2023-11-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-05 | 2023-11-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-10-05 | 2023-11-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-05 | 2023-11-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-05 | 2023-11-05 | 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 | 2023-10-05 | 2023-11-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-11-05 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-10 | 2023-10-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-01 | 2023-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-17 | 2023-03-14 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-22 | 2022-09-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-22 | 2022-09-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-02 | 2022-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-02 | 2022-01-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-02 | 2022-01-02 | 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 | 2021-12-02 | 2022-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-02 | 2022-01-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-02 | 2022-01-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-02 | 2022-01-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-02 | 2022-01-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-30 | 2021-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-30 | 2021-12-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-13 | 2020-07-02 | 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 | 2020-02-13 | 2020-07-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-13 | 2020-07-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-13 | 2020-07-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-13 | 2020-03-13 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-13 | 2020-03-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-13 | 2020-03-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-02-13 | 2020-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-13 | 2020-03-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
