A list of the most recent deficiencies for Bay Ridge 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? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-25 | 2022-10-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-25 | 2022-10-11 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-25 | 2022-10-04 | 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 | 2022-09-25 | 2022-10-04 | 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 | 2022-09-25 | 2022-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-25 | 2022-10-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-25 | 2022-10-03 | 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 | 2022-09-25 | 2022-10-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-25 | 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 | 2022-09-25 | 2022-10-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-25 | 2022-10-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-25 | 2022-10-03 | N |
| Post nurse staffing information every day. | Health | 2022-09-25 | 2022-10-03 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-25 | 2022-10-03 | 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 | 2022-09-25 | 2022-10-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-25 | 2022-10-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-09-25 | 2022-10-03 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-21 | 2022-10-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-11 | 2022-06-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-21 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-21 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-15 | Y |
| Report COVID19 data to residents and families. | Health | 2021-09-21 | 2021-10-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-03 | 2021-08-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-03 | 2021-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-03 | 2021-08-31 | 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 | 2021-08-03 | 2021-08-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-08-03 | 2021-08-31 | 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 | 2021-08-03 | 2021-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-05 | 2021-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-05 | 2021-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-05 | 2021-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-22 | 2019-09-18 | 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 | 2019-08-23 | 2019-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-23 | 2019-09-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-22 | 2019-09-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-22 | 2019-09-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-22 | 2019-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-09-10 | N |
