A list of the most recent deficiencies for South Bay Post Acute Care. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-25 | 2024-02-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-21 | 2022-12-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-21 | 2022-12-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-21 | 2022-12-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-21 | 2022-12-14 | 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 | 2022-11-21 | 2022-12-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-21 | 2022-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-21 | 2022-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-21 | 2022-12-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-21 | 2022-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-21 | 2022-12-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-21 | 2022-12-14 | 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 | 2022-11-21 | 2022-12-14 | 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 | 2022-11-21 | 2022-12-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-21 | 2022-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2022-12-14 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2022-11-21 | 2022-12-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-11-21 | 2022-12-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-21 | 2022-12-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-21 | 2022-12-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-11 | 2022-11-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-23 | 2022-10-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-23 | 2022-10-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-05 | 2022-08-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-05 | 2022-08-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-05 | 2022-08-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-05 | 2022-08-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-24 | 2022-07-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-24 | 2022-07-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-19 | 2022-06-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-04 | 2022-03-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-18 | 2021-08-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-10 | 2021-08-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-27 | 2021-07-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-27 | 2021-07-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-24 | 2021-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-07-12 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-05-24 | 2021-07-12 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-01-14 | 2019-03-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-14 | 2019-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-14 | 2019-03-07 | 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 | 2018-11-29 | 2019-01-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-29 | 2019-01-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-29 | 2019-01-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-29 | 2019-01-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-29 | 2019-01-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-11-29 | 2019-01-04 | 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 | 2018-11-29 | 2019-01-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-11-29 | 2019-01-04 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-11-29 | 2019-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-10-26 | 2017-12-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-10-26 | 2017-12-14 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2017-10-26 | 2017-12-14 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-10-26 | 2017-12-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-26 | 2017-12-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-10-26 | 2017-12-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-10-26 | 2017-12-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-26 | 2017-12-14 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-26 | 2017-12-14 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-10-26 | 2017-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-26 | 2017-12-14 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-10-26 | 2017-12-14 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-10-26 | 2017-12-14 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-10-26 | 2017-12-14 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-10-26 | 2017-12-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-11-14 | 2017-12-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-11-14 | 2017-12-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-14 | 2017-12-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-11-14 | 2017-12-05 | N |
