A list of the most recent deficiencies for Focused Care at Burnet Bay. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-11 | 2024-01-04 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-12-13 | 2023-12-28 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-12-13 | 2023-12-28 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-12-13 | 2023-12-28 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-12-13 | 2023-12-28 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-12-13 | 2023-12-28 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-12-13 | 2023-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-13 | 2023-12-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-13 | 2023-12-28 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-13 | 2023-12-28 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-13 | 2023-12-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-13 | 2023-12-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-25 | 2023-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-10-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-05 | 2022-11-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-05 | 2022-11-04 | N |
| Keep all essential equipment working safely. | Health | 2022-10-05 | 2022-11-04 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-10-04 | 2022-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-09 | 2021-11-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-24 | 2021-10-28 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-08-24 | 2021-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-24 | 2021-10-04 | 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 | 2021-08-24 | 2021-10-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-24 | 2021-10-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-08-24 | 2021-10-04 | Y |
| 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 | 2021-08-24 | 2021-10-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-23 | 2021-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-23 | 2021-10-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-23 | 2021-10-04 | N |
