Deficiency Records for Hudson Bay Health and Rehabilitation
Updated as of January 01, 2022
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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2019-12-13 | 2020-01-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-13 | 2020-01-03 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-09-10 | 2019-10-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-10 | 2019-10-28 | 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 | 2019-09-10 | 2019-10-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-10 | 2019-10-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-10 | 2019-10-28 | 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 | 2019-09-10 | 2019-10-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-10 | 2019-10-28 | 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 | 2019-09-10 | 2019-10-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-10 | 2019-10-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-10 | 2019-10-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-10 | 2019-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-10 | 2019-10-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-10 | 2019-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-10 | 2019-10-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-10 | 2019-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-10 | 2019-10-28 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-10 | 2019-10-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-10 | 2019-10-28 | N |
| Post nurse staffing information every day. | Health | 2019-09-10 | 2019-10-28 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-10 | 2019-10-28 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-09-10 | 2019-10-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-10 | 2019-10-28 | 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 | 2019-09-10 | 2019-10-28 | 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 | 2019-09-10 | 2019-10-28 | N |
| Provide or obtain dental services for each resident. | Health | 2019-09-10 | 2019-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-10 | 2019-10-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-10 | 2019-10-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-09-10 | 2019-10-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-10 | 2019-10-28 | 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 | 2019-09-10 | 2019-10-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-03 | 2019-10-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-13 | 2019-10-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-26 | 2019-10-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-08 | 2019-10-28 | Y |
| 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 | 2019-07-08 | 2019-10-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-08 | 2019-10-28 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-16 | 2019-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-16 | 2019-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-16 | 2019-10-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-16 | 2019-10-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-16 | 2019-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-16 | 2019-10-21 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-05-29 | 2019-06-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-05-17 | 2019-06-07 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-05-17 | 2019-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-17 | 2019-06-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-17 | 2019-06-07 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-04-09 | 2019-06-07 | 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 |
| 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 generator or other power source capable of supplying service within 10 seconds. | 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 |
