A list of the most recent deficiencies for The Medical Resort at Bay Area. 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? |
|---|---|---|---|---|
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-19 | 2023-09-20 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-19 | 2023-09-20 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-19 | 2023-09-20 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-09-19 | 2023-09-20 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-09-19 | 2023-09-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-19 | 2023-09-20 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-19 | 2023-09-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-19 | 2023-09-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-19 | 2023-09-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-19 | 2023-09-20 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-09-19 | 2023-09-20 | Y |
| 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 | 2023-09-19 | 2023-09-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-19 | 2023-09-20 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-09-19 | 2023-09-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-19 | 2023-09-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-19 | 2023-09-20 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-09-19 | 2023-09-20 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-19 | 2023-09-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-11 | 2023-08-25 | 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 | 2023-07-11 | 2023-08-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| 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 | 2023-02-09 | 2023-02-24 | Y |
| Keep all essential equipment working safely. | Health | 2023-02-09 | 2023-02-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-02 | 2022-10-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-02 | 2022-10-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-02 | 2022-10-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-19 | 2022-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-19 | 2022-05-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-08 | 2021-08-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-03 | 2021-07-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-03 | 2021-07-06 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-10-15 | 2020-12-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-10-15 | 2020-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-15 | 2020-12-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-15 | 2020-12-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-15 | 2020-12-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-10-15 | 2020-11-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-10-15 | 2020-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-15 | 2020-11-15 | 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 | 2020-10-15 | 2020-11-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-15 | 2020-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-15 | 2020-11-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-15 | 2020-11-15 | N |
| Post nurse staffing information every day. | Health | 2020-10-15 | 2020-11-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-15 | 2020-11-15 | 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 | 2020-10-15 | 2020-11-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-10-15 | 2020-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-15 | 2020-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-15 | 2020-11-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-10-15 | 2020-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-15 | 2020-11-15 | N |
