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Deficiency Records for Baptist Homes, Tri-County
A list of the most recent deficiencies for Baptist Homes, Tri-County. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Baptist Homes, Tri-County. 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-07-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-04 | 2023-04-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-04 | 2023-04-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-04 | 2023-04-20 | 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 | 2023-03-15 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-15 | 2023-04-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-20 | 2022-09-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-02 | 2022-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-10 | 2022-07-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-10 | 2022-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-10 | 2022-07-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-02 | 2022-07-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-03-02 | 2022-07-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-02 | 2022-07-22 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-03-02 | 2022-07-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-02 | 2022-07-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-03-02 | 2022-07-22 | 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 | 2022-03-02 | 2022-07-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-02 | 2022-07-22 | 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 | 2022-03-02 | 2022-07-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-02 | 2022-07-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-02 | 2022-07-22 | 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 | 2022-03-02 | 2022-07-22 | 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 | 2022-03-02 | 2022-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-02 | 2022-07-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-02 | 2022-07-22 | 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 | 2022-03-02 | 2022-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-02 | 2022-07-22 | Y |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2022-03-02 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-02 | 2022-07-22 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-02 | 2022-07-22 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-02 | 2022-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-02 | 2022-07-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-02 | 2022-07-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-02 | 2022-07-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-02 | 2022-04-21 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-03-02 | 2022-04-20 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-03-02 | 2022-04-20 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-03-02 | 2022-04-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-02 | 2022-04-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-02 | 2022-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-02 | 2022-04-20 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-02 | 2022-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-04-20 | 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 | 2022-03-02 | 2022-04-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-02 | 2022-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-02 | 2022-04-20 | Y |
| 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 | 2022-03-02 | 2022-04-20 | 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 | 2022-03-02 | 2022-04-20 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-02 | 2022-04-20 | 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 | 2022-03-02 | 2022-04-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-02 | 2022-04-20 | 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 | 2022-03-02 | 2022-04-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Meet other general requirements. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-13 | 2021-05-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-13 | 2021-05-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-13 | 2021-05-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-13 | 2021-05-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-11 | 2019-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-11 | 2019-08-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-11 | 2019-08-23 | 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 | 2019-07-11 | 2019-08-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-11 | 2019-08-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-11 | 2019-08-23 | 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 | 2019-07-11 | 2019-08-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-07-11 | 2019-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-07-11 | 2019-08-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Establish methods for sharing information. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-11 | 2019-08-23 | 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 | 2019-07-11 | 2019-08-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Meet other general requirements. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-08 | Not Fixed | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-02-08 | Not Fixed | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-08 | Not Fixed | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-08 | Not Fixed | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-02-08 | Not Fixed | N |
| Assess the resident when there is a significant change in condition | Health | 2024-02-08 | Not Fixed | 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 | 2024-02-08 | Not Fixed | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-08 | Not Fixed | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-08 | Not Fixed | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-08 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-08 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | Not Fixed | N |
| 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 | 2024-02-08 | Not Fixed | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-08 | Not Fixed | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Meet other general requirements. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-08 | Not Fixed | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-08 | Not Fixed | N |
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