A list of the most recent deficiencies for Kei-Ai South Bay Healthcare Center. 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-01-12 | 2024-02-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-12 | 2024-02-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-29 | 2024-01-27 | 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 | 2023-12-29 | 2024-01-27 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-12-29 | 2024-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-01-27 | 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 | 2023-12-29 | 2024-01-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-29 | 2024-01-27 | 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 | 2023-12-29 | 2024-01-27 | 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 | 2023-12-29 | 2024-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-29 | 2024-01-27 | 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 | 2024-01-02 | 2024-01-18 | 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 | 2024-01-02 | 2024-01-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-01-02 | 2024-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-02 | 2024-01-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-02 | 2024-01-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-02 | 2024-01-18 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-01-02 | 2024-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-29 | 2023-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-09 | Y |
| 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 | 2023-05-16 | 2023-06-16 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-05-16 | 2023-06-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-01 | 2023-06-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-18 | 2023-05-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-18 | 2023-05-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-06 | 2023-05-10 | 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 | 2023-03-03 | 2023-04-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-02 | 2023-04-01 | 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 | 2023-01-20 | 2023-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-10-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-04 | 2022-04-13 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-15 | 2022-03-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-04 | 2022-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-31 | 2022-02-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-03 | 2022-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-24 | 2022-01-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2021-10-01 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-14 | 2021-05-06 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-12 | 2021-05-03 | 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 | 2021-04-12 | 2021-05-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-12 | 2021-05-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-12 | 2021-05-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-12 | 2021-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-12 | 2021-05-03 | 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 | 2021-04-12 | 2021-05-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-12 | 2021-05-03 | 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 | 2021-04-12 | 2021-05-03 | 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 | 2021-04-12 | 2021-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-12 | 2021-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-12 | 2021-05-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-03-26 | 2021-04-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-10 | 2019-06-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-10 | 2019-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-10 | 2019-06-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-10 | 2019-06-25 | 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 | 2019-05-10 | 2019-06-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-10 | 2019-06-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-05-10 | 2019-06-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-10 | 2019-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-10 | 2019-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-10 | 2019-06-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-10 | 2019-06-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-05-10 | 2019-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-10 | 2019-06-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
