Bayshore Nursing & Rehab, GLENDALE, WI — Violations & Inspection Reports

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure services provided by the nursing facility meet professional standards of quality.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Implement a program that monitors antibiotic use.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Provide training in compliance and ethics.

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.

Provide and implement an infection prevention and control program.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Observe each nurse aide's job performance and give regular training.

Provide activities to meet all resident's needs.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Ensure each resident receives an accurate assessment.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

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.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

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.

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide care or services that was trauma informed and/or culturally competent.

Ensure residents have reasonable access to and privacy in their use of communication methods.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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.

PASARR screening for Mental disorders or Intellectual Disabilities

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Respond appropriately to all alleged violations.

Provide routine and 24-hour emergency dental care for each resident.

Ensure that residents are fully informed and understand their health status, care and treatments.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Reasonably accommodate the needs and preferences of each resident.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Post nurse staffing information every day.

Provide enough food/fluids to maintain a resident's health.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

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.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Provide training in compliance and ethics.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.