Deficiency Records for Hudson Bay Health and Rehabilitation
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-09-22 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-08 | 2023-06-05 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-05-08 | 2023-06-05 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-05-08 | 2023-06-05 | 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 | 2023-05-08 | 2023-06-05 | 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 | 2023-05-08 | 2023-06-05 | 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 | 2023-05-08 | 2023-06-05 | 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 | 2023-05-08 | 2023-06-05 | 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 | 2023-05-08 | 2023-06-05 | 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 | 2023-05-08 | 2023-06-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-08 | 2023-06-05 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-05-08 | 2023-06-05 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-05-08 | 2023-06-05 | N |
| Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2023-05-08 | 2023-06-05 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-08 | 2023-06-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-29 | 2022-10-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-01 | 2022-04-01 | Y |
| 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 | 2022-02-22 | 2022-04-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-22 | 2022-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-22 | 2022-04-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-22 | 2022-04-01 | 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 | 2022-02-22 | 2022-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-22 | 2022-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-22 | 2022-04-01 | 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 | 2022-02-22 | 2022-04-01 | 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 | 2022-02-22 | 2022-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-22 | 2022-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-04-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-22 | 2022-04-01 | 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 | 2022-02-22 | 2022-04-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-15 | 2022-03-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-15 | 2022-03-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-15 | 2022-03-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-15 | 2022-03-18 | N |
| 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 |
| Respond appropriately to all alleged violations. | 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 |
| 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 | 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 |
| 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 |
