Baywood Court Health Center

Based on interview, observation, and record review, the facility failed to remove discontinued controlled substances from the Med-Cart for Resident 30. The failure to ensure the proper disposition of discontinued controlled substances had the potential for administration to the resident or drug diversion. Findings: During a concurrent observation and interview on 10/8/24 at 10:55 with LVN1 the Med Cart A had multiple controlled medication in the locked bin that had been discontinued for Resident 30. LVN1 stated they are unaware of how long the medication had been there. The controlled discontinued medications included: 1 bottle of Morphine (Schedule II narcotic under the Controlled Substance Act) 100 mg/ml, with 9.25 ml remaining in bottle, 32 tablets of 1 mg Lorazepam (Schedule IV Controlled Substance), 69 tablets of .5 mg Lorazepam. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse (CN), the CN stated that the discontinued controlled medications should have been given to Charge Nurse or Director of Nursing (DON) for destruction and the medications should not be left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

During Observation, Interview and record review the facility failed to label multidose eye drops designed for multiple administrations for 4 out of 5 Residents. This failure had the potential for cross-contamination. Findings: During an observation on 10/8/24 at 10:55 a.m. with LVN 1, Med-Cart A contained 5 multidose eye drops for Resident 2, 7, 9, 20, and 23. (Artificial Tears, Liquid Gel Refresh, and Refresh Tears) with 4 of the 5 boxes labelled with room number only and not the Resident's name, for Residents 7, 9, 20, and 23. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse stated that multidose eye drops should have resident's full name on the box and not just the Resident's room number. Charge nurse stated this is done to prevent cross-contamination. During a review of Resident 2's Physician's Orders, dated 12/1/23, the physician ordered Carboxymethylcellulose sodium Refresh Tears (eye drops used to relieve dry, burning, irritated eyes), 1 drop to both eyes, PRN (as needed) for dry eyes. During a review of Resident 7's Physician's Orders, dated 7/3/23, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store ready to eat food under sanitary conditions to prevent contamination from dust. This improper food safety practice had the potential for food contamination resulting in food-borne illnesses. Findings: On 10/8/24 at 9:25 A.M. during an initial tour of the facility kitchen with the Executive Chef (EC), there were undated, open plastic bags of various breads: 6 pieces of english muffin, 5 slices of raisin bread, 3 pieces of bagel, 10 pieces of square bread, and 7 pieces of hamburger buns. These food items were exposed to dust and possible splash contamination as they were stored on a corner counter top with binders and small kitchen appliances. During an interview with the EC, she stated the plastics bags had to be closed and the binders and small appliances should have been in a separate area. 2022 Food Code, U.S Food and Drug Administration : 3-305 Preventing contamination from premises 3-305.11 Food Storage indicated food shall be protected from contamination by storing the food: (1) In a clean, dry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control practices for an already compromised resident (Resident 12) when oxygen and suction tubing were undated and of unknown age. This failure put Resident 12 at risk for healthcare-associated infections. Findings: During a review of Resident 12's admission record, Resident 12 was readmitted to the facility on [DATE] with a terminal diagnosis, and required suctioning and the provision of oxygen as needed. During observations on 10/8/24 at 11:05 A.M., 10/9/24 at 9:25 A.M. and 10/11/24 at 8:05 A.M., the suction tubing with a yankauer tip (a tool used to suction secretions in the mouth and throat) attached to it, and oxygen tubing at the bedside of Resident 12 did not have any dates on them. During an interview on 10/10/24 at 10:05 A.M. with Infection Preventionist (IP), IP stated the tubings needed to be dated. During a review of the facility's policy titled, Suctioning and revised August 2014, it indicated: #13. Change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were available and given according to the physician's order; and controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted, when: 1. A prescription medication for itching was not available for a resident upon request. This resulted in the resident enduring the itching unnecessarily. 2. Morphine (a potent medication for pain) was administered not administered as prescribed for Resident 2. This resulted in a medication error. 3. A random controlled medication use audit for four out of five residents (Residents 31, 50, 25, and 45) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented as given to the residents on the medication administration record (MAR). The failure had the potential to result in loss, misuse, and/or diversion of controlled and prescription medications. Findings: 1. During an observation and interview with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions, and medication refrigerator temperature log was complete, for one out of one medication room and two out of two medication carts, when: 1. Expired and discontinued controlled drugs were not removed from the medication carts. 2. Expired drugs were not removed from the medication room. 3. Expired drugs were not replaced or removed from the emergency Kit (eKit -a kit containing medications for emergency situations) in the medication refrigerator. 4. Medication refrigerator temperature logs were incomplete. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1A. During an inspection of the [NAME] Wing Medication Cart with licensed vocational nurse 2 (LVN 2) on 3/13/23, at 2:34 p.m., Four expired and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. water temperature in hand washing station in the kitchen was cold. 2. two dietary staff did not cover facial hair while inside the kitchen. 3. food items in upstairs kitchen refrigerator was not labeled, undated and was stored beyond used by date. 4. food stored in upstairs freezer was not labeled and dated. 5. vegetables in downstairs walk-in refrigerator was stored beyond use by date. 6. automatic ice machine dispenser had white and yellowish build up residue. 7. automatic ice machine filter was not changed according to manufacturer's guidelines. These failures had the potential to cause food contamination and food borne illness. Findings: 1. During an initial tour of the upstairs kitchen and concurrent interview on 3/13/23, at 9:39 a.m., with MS (Maintenance Director) 1, water in hand washing sink was cold after running it for 45 seconds. MS 1 checked water temperature with a thermometer (a measuring device), water temperature reached 88.3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure infection control practices were implemented when following was noted: 1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after handling Resident 33's dirty linen, and prior to handling clean personal clothing for Resident 22. 2. CNA 3 folded Resident 50's clean personal clothing while it was in contact with their own clothing. 3. Residents 10, 19, and 2's oxygen tubing was on the floor. 4. Resident 38's urinary catheter bag and tubing were touching the floor. 5. Resident 2's feeding pump pole had visible dirt and dried matter sticking to the base. 6. Licensed Vocational Nurse (LVN) 4 did not sanitize blood pressure cuff before and after use on Resident 29. 7. LVN 2 and LVN 4 did not perform hand hygiene before and after gloves changes during medication administration for Resident 2 and Resident 29 respectively. These failures placed facility's residents at risk for healthcare-associated infections. Findings: 1. During an observation on 3/14/23, at 11:17 a.m., in the laundry department,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label and provide a use by date on two of two food items kept in a refrigerator designated for food brought from outside the facility. Additionally, Facility did not ensure safe food handling practices for reheating food brought from outside the facility. These failures placed the facility residents at risk for food borne illnesses. Findings: During a concurrent observation and interview on 3/16/23, at 12:30 p.m., Certified Nurse Assistant 6 (CNA 6) reached into a 3.7 cubic foot refrigerator in the facility's conference room. CNA 6 then opened the freezer section and removed a sandwich-sized resealable unlabeled and undated plastic bag with frozen mixed vegetables. CNA 6 stated the frozen mixed vegetables were for Resident 1. CNA 6 stated facility stored residents food brought from outside the facility in that refrigerator. During a concurrent observation and interview with Charge Nurse (CN) on 3/16/23, at 1:11 p.m., following items were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide care with dignity for one of two sampled residents (Resident 21) when a Certified Nurse Assistant (CNA) did not provide privacy for Resident 21 while delivering personal care and preparing the resident for a shower. This deficient practice had the potential to affect Resident 21's sense of self-worth and self-esteem. Findings: A review of Resident 21's Face Sheet indicated Resident 21 was admitted to the facility with multiple diagnoses, including Alzheimer's disease and age-related physical debility. A review of Resident 21's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/13/19, indicated the resident's score was 08, meaning Resident 21's cognitive ability was mildly impaired. Resident 21's MDS also indicated Resident 21 required extensive assistance with bed mobility, moving from one surface to another, dressing, toilet use, and personal hygiene from one or more staff members and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two of two sampled residents (Residents 29 and 10), the facility failed to place their call lights within reach. This failure had the potential for Residents 29 and 10 to not receive urgently needed medical care or assistance with their activities of daily living (ADLs). Findings: 1. A review of Resident 29's Facesheet indicated Resident 29 was admitted with multiple diagnoses, including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one entire side of the body) affecting her right dominant side following a history of unspecified cerebrovascular disease (loss of blood flow to part of the brain). A review of Resident 29's Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/16/19 indicated Resident 29 needed extensive assistance with bed mobility, moving between surfaces, dressing, toilet use, and hygiene from one or more staff members. During an observation and concurrent interview with Resident 29 on 10/7/19 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, for one of two sampled residents (Resident 35), the facility failed to develop an individualized comprehensive care plan for the use of an antidepressant (a psychotropic medication capable of affecting the mind, emotions, and behavior) to treat depression (a mood disorder characterized by a feeling of sadness and a general loss of interest in activities). This deficient practice had the potential to negatively affect the delivery of medical care and services to Resident 35. Findings: A review of Resident 35's Facesheet indicated Resident 35 was admitted to the facility with multiple diagnoses, including major depressive disorder. A review of Resident 35's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/12/19, indicated the resident's score was 15, meaning Resident 35's cognitive ability was fully intact. A review of the progress notes in Resident 35's medical record showed a note written on 9/18/19 at 1:52 p.m. by Registered Nurse 1 (RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.