A list of the most recent deficiencies for Bywood East Health Care. 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 each resident receives an accurate assessment. | Health | 2024-01-22 | 2024-02-26 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-22 | 2024-02-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-22 | 2024-02-26 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-31 | 2023-09-23 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-08-31 | 2023-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-08-31 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-22 | 2023-03-10 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-12-22 | 2023-03-07 | N |
| Have an externally vented heating system. | Fire Safety | 2022-12-21 | 2023-02-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-22 | 2023-02-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-22 | 2023-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-02-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-22 | 2023-02-10 | 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 | 2022-12-22 | 2023-02-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-22 | 2023-02-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-22 | 2023-02-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-22 | 2023-02-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-22 | 2023-02-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-21 | 2023-02-10 | 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 | 2022-12-21 | 2023-02-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-21 | 2023-02-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-10 | 2022-11-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-10 | 2022-11-11 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-10 | 2022-11-11 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-10-10 | 2022-11-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-10 | 2022-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-07 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-07 | 2022-03-18 | Y |
| Report COVID19 data to residents and families. | Health | 2022-02-07 | 2022-03-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-07 | 2022-03-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-12 | 2021-09-29 | 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 | 2021-08-12 | 2021-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide or obtain dental services for each resident. | Health | 2021-08-12 | 2021-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-12 | 2021-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-12 | 2021-09-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-12 | 2021-09-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-09-07 | 2021-09-27 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-06-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-28 | 2021-06-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-16 | 2021-06-18 | 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 | 2021-04-12 | 2021-05-21 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-04-04 | 2019-05-31 | 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 | 2019-04-04 | 2019-05-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-04-04 | 2019-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-04 | 2019-05-31 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-04 | 2019-05-31 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-04-04 | 2019-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-04 | 2019-05-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-04 | 2019-05-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-04 | 2019-05-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-04-04 | 2019-05-31 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-04-04 | 2019-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-04 | 2019-05-31 | 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 | 2019-04-04 | 2019-05-31 | N |
| Provide or obtain dental services for each resident. | Health | 2019-04-04 | 2019-05-31 | 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 | 2019-04-04 | 2019-05-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-08 | 2019-05-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-04-04 | 2019-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-08 | 2019-04-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-08 | 2019-04-18 | N |
