Federal Nursing-Home Survey Record
BAYSIDE OF POQUOSON HEALTH AND REHAB
Does BAYSIDE OF POQUOSON HEALTH AND REHAB have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), BAYSIDE OF POQUOSON HEALTH AND REHAB (CCN 495264), in POQUOSON, VA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 12 deficiencies; the most serious carries scope/severity F on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2024-08-29. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 3.0
Deficiency timeline — full federal history
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
48 citations from earlier inspection cycles — historical, not current (expand)
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.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide safe and appropriate respiratory care for a resident when needed.
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Have a plan that describes the process for conducting QAPI and QAA activities.
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.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
Protect each resident from the wrongful use of the resident's belongings or money.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure services provided by the nursing facility meet professional standards of quality.
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.
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure that residents are free from significant medication errors.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Provide and implement an infection prevention and control program.
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Honor the resident's right to choose his or her attending physician.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate foot care.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Keep residents' personal and medical records private and confidential.
Reasonably accommodate the needs and preferences of each resident.
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.
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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.
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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.
Implement a program that monitors antibiotic use.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Perform COVID19 testing on residents and staff.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Document what happened
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