Deficiency Records for Bay Pointe Nursing Pavilion
Updated as of June 01, 2019
This is not the most recent data for Bay Pointe Nursing Pavilion. For the most recent information, click here.
A list of the most recent deficiencies for Bay Pointe Nursing Pavilion. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-16 | 2019-02-13 | Y |
| 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 | 2019-01-16 | 2019-02-13 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-01-16 | 2019-02-13 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-07 | 2019-01-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-07 | 2019-01-07 | 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 ne | Health | 2018-12-07 | 2019-01-07 | 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 | 2018-12-07 | 2019-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-07 | 2019-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-07 | 2019-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-26 | 2018-10-26 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-27 | 2018-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-29 | 2018-01-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-29 | 2018-01-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-12-29 | 2018-01-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-12-29 | 2018-01-29 | N |
| Provide or obtain dental services for each resident. | Health | 2017-12-29 | 2018-01-29 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-05-11 | 2017-06-11 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-05-11 | 2017-06-11 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-11 | 2017-06-11 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-04-13 | 2017-06-11 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-13 | 2017-06-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-04-13 | 2017-04-17 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-04-13 | 2017-04-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-17 | 2017-04-17 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2016-11-30 | 2017-01-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2016-11-30 | 2017-01-02 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-12-02 | 2017-01-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-02 | 2017-01-02 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-12-02 | 2017-01-02 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-02 | 2017-01-02 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-02 | 2017-01-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2016-12-02 | 2017-01-02 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-02 | 2017-01-02 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-12-02 | 2017-01-02 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-02 | 2017-01-02 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-02 | 2017-01-02 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-02 | 2017-01-02 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-02 | 2017-01-02 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2016-07-08 | 2016-08-08 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-07-08 | 2016-08-08 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-07-08 | 2016-08-08 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-07-08 | 2016-08-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-07-08 | 2016-08-08 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-07-08 | 2016-08-08 | Y |
