Deficiency Records for Bay Path at Duxbury Nursing and Rehabilitation Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Bay Path at Duxbury Nursing and Rehabilitation Ctr. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-24 | 2023-07-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-17 | 2023-06-30 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-17 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-24 | 2023-06-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-24 | 2023-06-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-24 | 2023-06-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-24 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-24 | 2023-06-02 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-01-21 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-21 | 2020-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-21 | 2020-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-14 | 2019-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-14 | 2019-12-20 | 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 | 2019-11-14 | 2019-12-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-14 | 2019-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-21 | 2018-12-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-16 | 2018-12-28 | N |
