Bayonet Point Health Center By Harborview

Based on observations, staff interviews and record review, the facility failed to maintain the kitchen and kitchen equipment in a sanitary and functional manner during two of four days observed (8/12/2024, 8/13/2024), related to; 1. Kitchen dish washing machine not operating per the machine's maintenance service specifications/recommendations; 2. Not maintaining ceiling vents above food preparation stations in a dust/debris free environment; and 3. Not maintaining the walk in freezer free from heavy ice build up on various boxes of food items. Findings included: 1. On 08/12/2023 at 9:10 a.m. the kitchen was toured with Dietary Manager. He provided a general kitchen tour of the kitchen and other kitchen spaces. The Dietary Manager was asked if he or his staff were utilizing the dish washing machine and he confirmed that a Dietary Aide Staff K was running the machine and has been doing so for about twenty minutes. The Dietary Manager revealed they are running a High Temperature dish washing machine and was being maintained by an outside dish washing machine maintenance service. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure two residents (#21 and #216) out of two residents with history of trauma had triggers identified to prevent re-traumatization. Findings included: Review of the admission Record showed Resident #216 was admitted to the facility on [DATE] with diagnoses that included but not limited to Post-Traumatic Stress Disorder (PTSD) Chronic, Schizoaffective Disorder, Bipolar Disorder, Generalized Anxiety Disorder and Major Depressive Disorder, Recurrent. Review of the baseline care plan showed no social service goals related to the diagnosis of PTSD or identified triggers. Review of the Informed Trauma Questionnaire dated 08/06/24 showed I. Assessment 1. Have you ever had an experience that was so upsetting to you that is changed you emotionally, spiritually, physically and behaviorally? Answer No. Review of the of Admission Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns showed Resident #216 had a Brief Interview for Mental Status (BIMS)…

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 observations, interviews and record review, the facility failed to ensure a quiet and homelike environment on one of four units (GNR 300), during three of four days observed (8/12/2024, 8/13/2024, 8/14/2024). It was observed and overheard a resident was yelling and causing loud noises for long periods of time and affecting Residents on the entire GNR 300 hallway to include Residents #32, #49, #15, #1, and 14. Findings included: On 8/12/2024 and 8/13/2024 during the 7-3 shift (over four observations from 9:55 a.m. - 10:45 a.m.), Resident #69 was observed in her room and lying flat in bed. She was observed all four times not presenting with any behaviors, pain or discomfort. Upon visiting the room she did present with confusion and cognitive deficits. Resident #69 was not able to answer specific questions related to her medical care and services. On 8/12/2024 at 11:00 a.m. while seated at the GNR 300 Nurses' Station, a resident could be overheard from the GNR 300 hall yelling out loud. The yelling was…

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 interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to ensure two residents (Resident #98 and #260) of the five residents sampled for baseline care plans. The findings include: Review of Resident #98's admission record revealed an admission date of 6/25/2024 with diagnoses of coronary artery bypass graft(s) with complications, urinary retention, Percutaneous endoscopic gastrostomy (PEG) tube, and other co-morbidities Review of Resident #98's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 6/25/2024 revealed resident at risk for falls, resident has a foley catheter, a PEG tube, and diet order of NPO (nothing by mouth). Review of Resident #98's Interim Care Plan dated 6/25/2024 and completed 7/8/2024 revealed no care plan for a urinary catheter, nor dietary instructions for PEG tube. Review of Resident #260's admission record revealed an admission date of 7/24/2024 with diagnoses of chronic obstructive pulmonary disease with exacerbation (COPD), Pulmonary…

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, interviews, and record review, the facility failed to follow their policy to 1. store medications appropriately in three of five (100-400 Hall) medication carts, failed to ensure controlled substances were appropriately stored in a locked drawer in one of two medications storage rooms (SSU Hall), and did not ensure expired tuberculin testing syringes were disposed of in one of two medication storage room refrigerators (100-300 Hall); 2. Failed to appropriately secure medications for two Residents (#67 and #334) of four residents. Findings included: A facility provided policy titled, Medication Storage, with no date, Page 01 of 01, was reviewed and read Policy: Medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Access to medications is limited to only authorized personnel. Procedure: 1. Storage areas may include, but are not limited…

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 observations, resident record, and interviews, the facility failed to develop care plan problem areas with interventions related to behaviors and the development of a potential rash for one (Resident #29) of thirty-eight sampled residents. Findings included: On 7/25/2022 at 10:00 a.m. and 12:40 p.m., Resident #29 was observed in her room and lying in bed. Both her left and right forearms and shoulder areas revealed multiple small scabbed areas. She was asked about her arms and she revealed staff had told her to stop scratching. She said she had tried to control her scratching and indicated the scabbed areas were from a rash that she could not explain. On 7/26/2022 at 11:40 a.m., Resident #29 was noted in her room with three staff members. The staff were about to transfer her from her wheelchair back to bed after she just returned from receiving a shower. The resident was observed with all the same scabbed areas on both her forearms and shoulders. The staff in the room could not explain the scabbed areas…

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 interviews and record review, the facility failed to ensure behavior monitoring was in place for one (Resident #67) of three sampled residents on psychotropic medications. Findings Included: A review of admission records indicated Resident #67 was admitted on [DATE] with diagnoses including atrial fibrillation, unspecified dementia without behavioral disturbances, and alcohol abuse. A review of orders revealed an order for SEROquel Tablet 25 milligrams (mg). Give 25 mg by mouth at bedtime related to Unspecified .Dementia without Behavioral Disturbances. Start date: 01/04/22. Review of the electronic Medication Adminsitration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the months of May, June, and July of 2022 did not include any behavior or side effects monitoring for psychotropic medications. Resident #67's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C. (Cognitive Patterns) revealed Resident #67 had a BIMS (Brief Interview for Mental Status) score of 1,…

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 observations and staff interviews, the facility failed to post the total number, and the actual hours worked of the direct care staff for the benefit of the facility residents and the public on 04/05/21 through 04/07/21 as evidenced by the position and location of the clipboard that was identified by the Staffing Coordinator as the posting location. Findings included Upon entry to the facility at approximately 09:00 am on Monday 04/05/21 surveyors did not observe the information required by statutes concerning the posting for the nurse staffing information. The nurse posting information was not available for viewing until the last day of the survey, 04/08/21, when the staffing coordinator stated that the information was on a clipboard at one of the nursing stations. The staffing coordinator identified the location as being on the wall to the right of the skilled step-down unit (SSU). The observed clipboard was not identified as holding the staffing information and hung in a manner that did not allow viewing for visitors or any other passerby unless they knew to take it off…

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 observations, interviews and record review the facility did not ensure that Controlled substances were locked and stored in a permanently affixed compartment in two of two medication storage rooms sampled. Findings included: On 04/07/21 at 10:28 a.m. during the performance of the medication storage and labeling task the locked medication room on the Skilled Subacute Unit (SSU) inspection of the refrigerator in the same medication room at 10:30 a.m. accessed by Staff A, LPN, revealed a locked box. The box was not secured or maintained in a permanently affixed compartment in the refrigerator. Staff A, LPN unlocked the box, which revealed two clear plastic cases. The clear plastic cases were sealed with a green tamper proof seal and the contents could be seen through the plastic. Each plastic case contained three, 2mg/ml vials of the controlled substance lorazepam (photographic evidence was obtained). An interview with Staff A, LPN. He stated that he was not aware that the box containing control substances lorazepam had to be secured in a permanently affixed compartment. 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.