Deficiency Records for Brown Cty Comm Treatment Ctr-Bayshore Village
Updated as of March 01, 2024
A list of the most recent deficiencies for Brown Cty Comm Treatment Ctr-Bayshore Village. 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-08-30 | 2023-09-30 | 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 | 2023-08-30 | 2023-09-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-30 | 2023-09-30 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-08-30 | 2023-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-30 | 2023-09-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-30 | 2023-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-29 | 2023-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-29 | 2023-09-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-08-29 | 2023-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-29 | 2023-09-30 | 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 | 2022-09-08 | 2022-10-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-08 | 2022-10-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-10-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-08 | 2022-10-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-08 | 2022-10-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-09 | 2022-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-09 | 2022-10-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-09 | 2022-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-09 | 2022-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-09 | 2022-10-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-21 | 2022-03-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-21 | 2022-03-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-28 | 2021-08-28 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-28 | 2021-08-28 | 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 | 2021-07-28 | 2021-08-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-28 | 2021-08-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-28 | 2021-08-28 | 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 | 2021-07-28 | 2021-08-28 | 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 | 2021-07-26 | 2021-08-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-26 | 2021-08-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-26 | 2021-08-28 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-07-26 | 2021-08-28 | N |
