Deficiency Records for Bayside of Poquoson Health and Rehab
Updated as of April 01, 2024
A list of the most recent deficiencies for Bayside of Poquoson Health and Rehab. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-27 | 2023-05-19 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-05-11 | 2021-07-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-11 | 2021-07-29 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-11 | 2021-07-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-11 | 2021-07-29 | N |
| 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 | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-11 | 2021-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-11 | 2021-07-29 | N |
| Provide appropriate foot care. | Health | 2021-05-11 | 2021-07-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-11 | 2021-07-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-11 | 2021-07-29 | N |
| 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 | 2021-05-11 | 2021-07-29 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-11 | 2021-07-29 | 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 | 2021-05-11 | 2021-07-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-11 | 2021-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-11 | 2021-07-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-05-11 | 2021-07-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-11 | 2021-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-11 | 2021-07-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-11 | 2021-07-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-05-11 | 2021-07-29 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-11 | 2021-07-29 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2021-05-11 | 2021-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-11 | 2021-07-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-11 | 2021-07-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-11 | 2021-07-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-11 | 2021-07-29 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-11 | 2021-07-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-11 | 2021-07-29 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-13 | 2020-02-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-13 | 2020-02-12 | 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 | 2019-12-13 | 2020-02-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-12-13 | 2020-02-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-13 | 2020-02-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-13 | 2020-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-13 | 2020-02-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-16 | 2019-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-16 | 2019-09-16 | 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 | 2019-08-16 | 2019-09-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-16 | 2019-09-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-16 | 2019-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-16 | 2019-09-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-08-16 | 2019-09-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-16 | 2019-09-16 | 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 | 2019-08-16 | 2019-09-16 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-08-16 | 2019-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-16 | 2019-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-16 | 2019-09-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-21 | 2018-11-30 | 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 | 2018-09-21 | 2018-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-21 | 2018-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-21 | 2018-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-21 | 2018-11-30 | 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 | 2018-09-21 | 2018-10-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-21 | 2018-10-31 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-09-21 | 2018-10-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-21 | 2018-10-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-21 | 2018-10-31 | 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 | 2018-09-21 | 2018-10-31 | 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 | 2018-09-21 | 2018-10-31 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-21 | 2018-10-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-09-21 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-21 | 2018-10-31 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-09-21 | 2018-10-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-21 | 2018-10-31 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-09-21 | 2018-10-13 | N |
