Hudson Bay Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hudson Bay Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF906May 8, 2023

  Based on observation and interview, the facility failed to ensure the required Type 1 essential electrical system (EES) and generator was in place and operational prior to accepting residents to a ventilator unit where an emergency electrical power system would be needed to maintain life support equipment in the event of a power outage for 3 of 3 sampled ventilator residents (116, 119 & 300) reviewed for emergency electrical power system. This failure placed Resident 116, Resident 119 and Resident 300, all dependent on life support equipment, at risk for loss of life. An Immediate Jeopardy was called on 05/02/2023 at 2:40 PM when the facility failed to have adequate emergency electrical system including emergency life support to residents on ventilators in case of a power outage. […]

• No harm, potential for more than minimal, widespreadF812Jun 7, 2024

  Based on observation and interview, the facility failed to maintain the cleanliness of the vent covers in 1 of 1 facility kitchen. This failure placed residents at risk to consume food not prepared in a sanitary manner and a diminished quality of life. kitchen vent covers reviewed for kitchen. These failures had the potential to affect all residents who consumed food and may cause a diminished quality of life. Findings included . On 06/06/2024 at 10:05 AM, the overhead vent covers (located over the food prep areas) were observed with lint trapped between the grilles. The stove hood filters appeared to be greasy and had some lint between the grilles. At 2:07 PM, when asked what was in the overhead vents above the food prep area, Staff F, Dietary Manager, said it looked like lint. […]

• No harm, potential for more than minimal, widespreadF550May 8, 2023

  Based on interview and record review, the facility failed to ensure new residents were given and explained admission documents for 15 of 15 sampled residents (2, 4, 5, 6, 8, 16, 18, 21, 24, 28, 32, 36, 47, 110 & 119) reviewed for resident rights. This failure placed residents and representatives at risk of not being fully informed of their rights as residents, unmet care needs, and a decreased quality of life. Findings included Record review of a blank admission packet, undated, showed the following forms should have been included: Bed-hold Policy, Resident Rights, How to File Concerns/Grievances, Firearm Policy, Key Personnel List, Smoking Policy, Resident Trust Fund Authorization, SNF (Skilled Nursing Facility) Determination on Admission, and Notice of Privacy Information Practices. […]

• No harm, potential for more than minimal, widespreadF574May 8, 2023

  Based on interview and record review, the facility failed to ensure residents were provided information regarding filing a complaint concerning suspected violations of State and Federal nursing facility regulations and failed to ensure residents were provided a list of names, mailing and email address and phone numbers of State Agency, informational agencies and advocacy groups in a manner they understand for 10 of 10 sampled residents (6, 7, 14, 19, 34, 45, 47, 255, 260 & 261) reviewed for notices and contact information. These failure placed residents and representatives at risk of not being fully informed of their rights, ways to file a complaint, ways to access advocacy groups, and a diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF576May 8, 2023

  Based on interview and record review, the facility failed to ensure mail delivery was provided on Saturdays for all facility residents receiving letters, packages, or other materials delivered to the facility for 10 of 10 sampled residents (6, 7, 14, 19, 34, 45, 47, 255, 260 & 261) reviewed for communication and privacy. This failure placed resident at risk of not have their right honored to receive and send communication through the mail and a diminished quality of life. Findings included . Record review of the blank facility Admission Agreement-Resident Rights, undated, page 10, notes, 36. […]