Deficiency Records for Fort Bayard Medical Center
Updated as of March 01, 2020
This is not the most recent data for Fort Bayard Medical Center. For the most recent information, click here.
A list of the most recent deficiencies for Fort Bayard Medical Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-28 | 2019-08-21 | 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 | 2019-06-28 | 2019-08-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-28 | 2019-08-21 | 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 | 2019-06-28 | 2019-08-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-28 | 2019-08-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-06-28 | 2019-08-21 | 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 | 2019-06-28 | 2019-08-21 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-06-28 | 2019-08-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-28 | 2019-08-21 | 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 | 2019-06-28 | 2019-08-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-28 | 2019-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-28 | 2019-08-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-06-28 | 2019-08-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-06-25 | 2019-07-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-25 | 2019-07-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-09 | 2018-06-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-09 | 2018-06-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-05-10 | 2018-06-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-05-10 | 2018-06-15 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-10 | 2018-06-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-10 | 2018-06-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-10 | 2018-06-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-10 | 2018-06-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-05-10 | 2018-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-06-13 | 2017-07-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-06-13 | 2017-07-20 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-06-20 | 2017-07-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-20 | 2017-07-20 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-06-20 | 2017-07-14 | N |
| 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 | 2017-06-20 | 2017-07-14 | 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 | 2017-06-20 | 2017-07-14 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-06-20 | 2017-07-14 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-20 | 2017-07-14 | Y |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-06-20 | 2017-07-10 | N |
