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Deficiency Records for Bay Harbor Post Acute Healthcare Center
View the most recent health deficiencies and inspection results for Bay Harbor Post Acute Healthcare Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Bay Harbor Post Acute Healthcare Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2025-10-17 | 2025-12-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-10-17 | 2025-12-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2025-10-17 | 2025-12-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-10-17 | 2025-12-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-10-17 | 2025-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-10-17 | 2025-12-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-10-17 | 2025-12-02 | Y |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2025-10-17 | 2025-12-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-10-17 | 2025-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-10-17 | 2025-12-02 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Meet other general requirements. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-01-17 | 2025-04-22 | 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 | 2025-01-17 | 2025-04-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-01-17 | 2025-04-22 | 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 | 2025-01-17 | 2025-04-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-01-17 | 2025-04-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2025-01-17 | 2025-03-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-01-17 | 2025-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-01-17 | 2025-03-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2025-01-17 | 2025-03-19 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2025-01-17 | 2025-03-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | N |
| Post nurse staffing information every day. | Health | 2025-01-17 | 2025-03-19 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2025-01-17 | 2025-03-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-01-17 | 2025-03-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-01-17 | 2025-03-19 | Y |
| 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 | 2025-01-17 | 2025-03-19 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-17 | 2025-03-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-17 | 2025-03-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2025-01-17 | 2025-03-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-01-17 | 2025-03-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-01-17 | 2025-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-01-17 | 2025-03-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-01-17 | 2025-03-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-01-17 | 2025-03-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-01-17 | 2025-03-19 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-01-17 | 2025-03-19 | 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 | 2025-01-17 | 2025-03-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-01-17 | 2025-03-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-01-17 | 2025-03-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2025-01-17 | 2025-03-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2025-01-17 | 2025-03-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2025-01-17 | 2025-03-19 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2025-01-17 | 2025-03-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-01-17 | 2025-03-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-01-17 | 2025-03-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2025-01-17 | 2025-03-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-28 | 2024-05-10 | 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 | 2024-02-28 | 2024-05-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-28 | 2024-05-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-28 | 2024-04-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-28 | 2024-04-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-28 | 2024-04-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-28 | 2024-04-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-28 | 2024-04-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-28 | 2024-04-11 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-02-28 | 2024-04-11 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-28 | 2024-04-11 | Y |
| Keep all essential equipment working safely. | Health | 2024-02-28 | 2024-04-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-28 | 2024-04-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-28 | 2024-04-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-04-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-28 | 2024-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-28 | 2024-04-11 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-10-16 | 2020-01-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-16 | 2019-11-28 | N |
| Keep all essential equipment working safely. | Health | 2019-10-16 | 2019-11-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-16 | 2019-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-16 | 2019-11-28 | 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 | 2019-10-16 | 2019-11-28 | 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 | 2019-10-16 | 2019-11-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-16 | 2019-11-28 | 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 | 2019-10-16 | 2019-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-11-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-18 | 2018-07-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-06-18 | 2018-07-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-18 | 2018-07-31 | 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 | 2018-06-18 | 2018-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-18 | 2018-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-18 | 2018-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-18 | 2018-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-18 | 2018-07-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-18 | 2018-07-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-18 | 2018-07-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-06-18 | 2018-07-25 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-06-18 | 2018-06-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-18 | 2018-06-22 | 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 | 2018-06-18 | 2018-06-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-06-18 | 2018-06-22 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-06-18 | 2018-06-22 | 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 | 2026-04-17 | Not Fixed | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2026-04-17 | Not Fixed | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-04-17 | Not Fixed | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2026-04-17 | Not Fixed | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-04-17 | Not Fixed | Y |