The Villages Of General Baptist Health Care West
Inspection History Overview
Detailed Inspection Reports
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Fines and Penalties by Year
2021 5 penalties totaling $16,638
Fine
Fine
Fine
Fine
Fine
2020 2 penalties totaling $20,521
Fine
Payment Denial
2019 2 penalties totaling $6,633
Fine
Payment Denial
2017 2 penalties totaling $166,794
Fine
Payment Denial
Health Violations by Year
2024 6 violations
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have policies on smoking.
2023 23 violations
Honor the resident's right to manage his or her financial affairs.
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 activities to meet all resident's needs.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
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 a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
2022 21 violations
Honor the resident's right to manage his or her financial affairs.
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Assure the security of all personal funds of residents deposited with the facility.
Assure that each residentβs assessment is updated at least once every 3 months.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide safe and appropriate respiratory care for a resident when needed.
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 medication error rates are not 5 percent or greater.
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.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Report COVID19 data to residents and families.
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.
Keep all essential equipment working safely.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
2021 26 violations
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide and implement an infection prevention and control program.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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.
Assure that each residentβs assessment is updated at least once every 3 months.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate foot care.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure medication error rates are not 5 percent or greater.
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.
2020 7 violations
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide and implement an infection prevention and control program.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide and implement an infection prevention and control program.
2019 23 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Notify the resident or the residentβs representative in writing how long the nursing home will hold the residentβs bed in cases of transfer to a hospital or therapeutic leave.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
PASARR screening for Mental disorders or Intellectual Disabilities
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 enough food/fluids to maintain a resident's health.
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 safe and appropriate respiratory care for a resident when needed.
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide care and assistance to perform activities of daily living for any resident who is unable.
2018 11 violations
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.
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 timely, quality laboratory services/tests to meet the needs of residents.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
Provide and implement an infection prevention and control program.
Provide or get specialized rehabilitative services as required for a resident.
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.
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Provide enough food/fluids to maintain a resident's health.
2017 17 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure each resident receives an accurate assessment by a qualified health professional.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Store, cook, and serve food in a safe and clean way.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
Provide food in a way that meets a resident's needs.
Store, cook, and serve food in a safe and clean way.