Deficiency Records for Bay Pointe Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Bay Pointe Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-16 | 2023-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-24 | 2023-10-08 | N |
| 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 | 2023-08-24 | 2023-10-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-24 | 2023-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-24 | 2023-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-24 | 2023-10-08 | 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 | 2023-08-24 | 2023-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-24 | 2023-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-24 | 2023-10-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-24 | 2023-10-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-24 | 2023-10-08 | 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 | 2023-08-24 | 2023-10-08 | N |
| Post nurse staffing information every day. | Health | 2023-08-24 | 2023-10-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-08-24 | 2023-10-08 | 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 | 2023-08-24 | 2023-10-08 | 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 | 2023-08-24 | 2023-10-08 | 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 | 2023-08-24 | 2023-10-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-24 | 2023-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-24 | 2023-10-08 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-08-24 | 2023-10-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-24 | 2023-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-27 | 2023-05-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-27 | 2023-04-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-27 | 2023-04-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-27 | 2023-04-27 | Y |
| 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 | 2023-02-27 | 2023-04-27 | 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 | 2023-02-27 | 2023-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-27 | 2023-04-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-27 | 2023-04-27 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-02-27 | 2023-04-27 | 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 | 2023-02-27 | 2023-04-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-27 | 2023-04-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-27 | 2023-04-27 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-15 | 2021-12-21 | N |
| 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 | 2021-10-15 | 2021-12-21 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2021-10-15 | 2021-12-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-15 | 2021-12-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-15 | 2021-12-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-15 | 2021-12-21 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-15 | 2021-12-21 | 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 | 2021-10-15 | 2021-12-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-15 | 2021-12-21 | 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 necessary and PRN use is limited. | Health | 2021-10-15 | 2021-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-15 | 2021-12-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-11-28 | 2019-01-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-28 | 2019-01-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-11-28 | 2019-01-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-11-28 | 2019-01-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-28 | 2019-01-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-26 | 2018-12-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-10-26 | 2018-12-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-26 | 2018-12-10 | N |
| 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 | 2018-10-26 | 2018-12-10 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-10-26 | 2018-12-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-26 | 2018-12-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-26 | 2018-12-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-26 | 2018-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-26 | 2018-12-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-26 | 2018-12-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-26 | 2018-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-26 | 2018-12-10 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-10-26 | 2018-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-26 | 2018-12-10 | N |
