Deficiency Records for Hudson Bay Health and Rehabilitation
Updated as of March 01, 2019
This is not the most recent data for Hudson Bay Health and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Hudson Bay Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-30 | 2018-12-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-15 | 2018-12-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-11-15 | 2018-12-11 | 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 | 2018-11-15 | 2018-12-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-11-15 | 2018-12-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-15 | 2018-12-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-15 | 2018-12-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-15 | 2018-12-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-11-15 | 2018-12-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-15 | 2018-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-15 | 2018-12-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-11-15 | 2018-12-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-15 | 2018-12-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-15 | 2018-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-15 | 2018-12-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-15 | 2018-12-11 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-30 | 2017-12-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-10-30 | 2017-12-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-30 | 2017-12-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2017-10-30 | 2017-12-04 | N |
| Provide housekeeping and maintenance services. | Health | 2017-10-24 | 2017-11-29 | N |
| Assess in a timely manner the resident when the resident enters the nursing home. | Health | 2017-10-24 | 2017-11-29 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-24 | 2017-11-29 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-24 | 2017-11-29 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-24 | 2017-11-29 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-24 | 2017-11-29 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-24 | 2017-11-29 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-24 | 2017-11-29 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-24 | 2017-11-29 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-24 | 2017-11-29 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-24 | 2017-11-29 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-10-13 | 2017-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-13 | 2017-11-13 | Y |
| 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 | 2017-07-20 | 2017-08-15 | Y |
| 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 | 2016-09-01 | 2016-10-12 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-09-01 | 2016-10-12 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-09-01 | 2016-10-12 | N |
| Provide housekeeping and maintenance services. | Health | 2016-09-01 | 2016-10-12 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-09-01 | 2016-10-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-09-01 | 2016-10-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-09-01 | 2016-10-12 | N |
| Approved construction type or materials. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Properly maintained smoke detectors. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Portable fire extinguishers. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-09-01 | 2016-10-03 | N |
