Bay Pointe Nursing Pavilion

Based on observations, record reviews and interviews the facility failed to ensure shift to shift controlled substance logs were complete and accurate for five hall logs (100, 300, 400, 500, and 600) out of six controlled substance logs reviewed. Findings included: On 4/8/26 at 9:12 a.m. during an observation, interview and narcotic count verification of the 400 Hall even cart with Staff A, Licensed Practical Nurse (LPN), the controlled substance key exchange audit (CSKEA)form used to document controlled medications and medication cart key exchange was noted blank. There were no signatures by the off going or oncoming nurse. Staff A, LPN said controlled medications were counted at the beginning of the shift and stated she did not sign the form. Staff A, LPN was also assigned to the 300 Hall cart, and the CSKEA form was not signed. Staff A, LPN was observed signing the oncoming nurse column. On 4/8/26 at 9:51 a.m. during an observation, interview and narcotic count verification of the 400 Hall odd and 500 Hall carts with Staff B, Registered Nurse (RN). Staff B, RN had signed 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, record review and interviews the facility failed to ensure medications were stored and labeled in accordance with professional standards. Observations included refrigerated medications stored outside of required temperature controls, medications lacking open dates, and failure to properly dispose of single-dose vials after use in one med cart (600) of six medication carts sampled.Findings Included: On 4/8/26 at 9:57 a.m. during interview, observation and narcotic count verification of the 600 Hall cart with Staff C, Licensed Practical Nurse (LPN). An opened undated vial of Ativan 20mg/10ml (milligram/milliliter) was in the controlled medication drawer. The clear plastic bag containing the vial was affixed with a sticker containing but not limited to, resident's name, medication issue date 9/24/25, medication strength and instructions to keep in the refrigerator. The label on the vial did not have an open or expiration date written on the label and the vial did not contain markings to check the volume of the medication. Staff C, LPN said she knows there is…

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 review of facility records, staff and resident interviews, the facility failed to ensure sufficient staffing to meet the needs of the residents as evidenced by, 1. Resident interviews on untimely call light response for five residents (#11, #14, #15, #10 and #16) of 8 residents sampled, 2. Unresolved grievances related to call light response times for one resident (#11) of five residents reviewed for grievances. Findings included: On 3/10/25 at 2:20 p.m., an interview was conducted with Resident #11 who stated, depending on who's working the call light response varies. Resident #11 said, There is definitely a problem on nights and weekends where it can be up to an hour before someone answers the call light. A review of Resident #11's admission record revealed the resident was admitted to the facility on [DATE], with diagnoses to include nontraumatic intracerebral hemorrhage, muscle wasting, and atrophy. Review of Resident #11's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental…

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 interview and record review, the facility failed to ensure Hemodialysis (HD) care was provided per physician orders for one (Residents #1) of six residents receiving dialysis. Findings included: Resident #1 was admitted to the facility on [DATE] and discharged on 03/09/24 with diagnoses to include End Stage Renal Disease (ESRD) and Dependence on renal dialysis. Review of the facility's grievance log showed on 03/11/24, a grievance was filed for Resident #1. Review of the grievance submitted by the resident's family member showed Resident missed dialysis on 03/09/24 and was late on 03/07/24 due to transportation. Review of physician orders for Resident #1 dated 03/06/24 showed the resident did not have orders for hemodialysis. Review of physician orders for Resident #1 dated 04/02/24 showed the resident is to have Dialysis on days: Tuesday, Thursday, Saturday at [name and location of Dialysis center] Chair time: 6 AM Catheter site: Right and Left Upper Arms Dialysis Transport:[name of transportation…

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 one resident (#81) out of five residents sampled was accurately assessed for pain in Section J- Health Conditions on the Minimum Data Set (MDS) assessment. Findings included: During an interview on 01/09/24 at 9:45 a.m., Resident #81 stated she had pain in her feet. Resident #81 could not answer why her feet hurt but stated, They just hurt. Review of Resident #81's admission Record showed diagnoses including muscle wasting and atrophy, multiple sites, chronic pain syndrome, low back pain, foot drop, and pain unspecified. Review of Resident #81's current physician orders showed the following medications for pain: - A physician order dated 10/09/23 showed Baclofen Oral Tablet 10 MG [milligrams] give one tablet by mouth three times a day for pain. - A physician order dated 10/10/23 showed Norco Oral Tablet 5-356 MG [milligrams] give one tablet by mouth every six hours as needed for pain. - A physician order dated 11/10/23 showed Lidocaine HCI…

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 interviews the facility failed to refer one resident (#78) of 12 residents reviewed for Pre-admission Screening and Resident Review (PASRR), for a Level II review after a positive Level I PASRR revealed a need for further review. Findings included: Review of Resident #78's admission Record showed an original admission date of 07/28/23 with diagnoses included but not limited to unspecified mood [Affective] disorder onset date 07/28/23, other psychotic disorder onset date 07/28/23, Schizoaffective Disorder, Bipolar Type onset 12/14/23, Major Depressive Disorder, recurrent, moderate onset date 12/14/23, Schizoaffective Disorder, unspecified onset date 07/28/23, Bipolar Disorder, unspecified onset date 07/28/23 and generalized anxiety disorder onset date 10/19/23. Review of Resident #78's Discharge Return Anticipated Minimal Data Set (MDS) assessment dated [DATE], revealed under Section C-Cognitive Patterns, Resident #6 had a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive…

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 implement and develop a care plan for a Functional Maintenance program/Restorative Nursing program for one resident (#17) out 34 sampled residents. Findings included: Review of Resident #17's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included lack of coordination, repeated falls, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, acquired deformities of right foot, age related physical debility, personal history (healed) of traumatic fracture, and presence right artificial hip joint. An interview was conducted on 1/9/24 at 10:22 AM with Resident #17. She was observed to be in her room sitting in her wheelchair. She said she was not currently in therapy, but she feels she was making progress in therapy and now that she is no longer in therapy she feels she is not able to lift herself from the wheelchair and use her walker as well as she…

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 provide a Functional Maintenance program/Restorative Nursing program to maintain or improve resident activities of daily living (ADLs) for one resident (#17) out three residents reviewed for activities of daily living. Findings included: Review of Resident #17's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included but are not limited to lack of coordination, repeated falls, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, acquired deformities of right foot, age related physical debility, personal history (healed) of traumatic fracture, and presence right artificial hip joint. An interview was conducted on 1/9/24 at 10:22 AM with Resident #17. She was observed to be in her room sitting in her wheelchair. She said she was not currently in therapy, but she feels she was making progress in therapy and now that she is no longer in therapy she…

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, record review, and interviews, the facility failed to maintain emergency supplies for tracheostomy care at bedside per physician's order and failed to obtain orders prior to administering oxygen for one resident (Resident #14) out of two sampled residents. Findings included: On 01/10/24 at 9:30 a.m., the oxygen concentrator in Resident #14's room was observed on and set at 5 liters. On 01/12/24 at 9:40 a.m., the oxygen concentrator in Resident #14's room was observed on and set at 5 liters, the humidified air was set at 28%. The opposite end of the tubing connector attached to the oxygen concentrator was observed disconnected from the tracheostomy (trach) collar and on the floor. A review of the admission Record for Resident #14 showed the resident was initially admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure with hypoxia, tracheostomy status, and respiratory disorders in diseases classified elsewhere. A review of the Quarterly Minimum Data Set…

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, staff interview, and record review, the facility failed to accurately complete the two most current Minimum Data Set (MDS) assessments, and the two most current Nursing Quarterly assessments for one (Resident #48) of thirty-six sampled residents. Findings included: During observations on 10/11/2021 at 1:00 p.m., 10/12/2021 at 12:50 p.m., and 10/13/2021 at 12:45 p.m. and 2:10 p.m., Resident #48 was seated either in her room, the main dining room, or out in the smoking courtyard. During these observed times, Resident #48 was seated, slightly reclined, in a padded [Brand name] chair. Further observations revealed thigh straps that were attached to the chair and both of her legs. These straps were observed preventing her from rising up from the chair. Resident #48 was not able to self release these straps, and therefore they were identified as a trunk restraint. Resident #48 did not present with any behaviors, pain, or discomfort related to the trunk restraint. An interview with the [NAME]…

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 strawberries were stored and maintained in a safe and sanitary manner, and failed to appropriately store kitchen staff's drinks in two (2) of three (3) refrigerators sampled. Findings included During the initial kitchen tour on 11/24/19 at 9:45 a.m., an observation of the walk-in refrigerator included on the second shelf, a cardboard box that contained two (2) boxes of moldy strawberries. (Photographic Evidence Obtained.) Staff A, Kitchen Cook, confirmed the presence of both boxes of moldy strawberries, and quickly removed them throwing them into a nearby garbage receptacle. On 11/24/19 at 9:45 a.m. during an observation of the cook's refrigerator a white plastic bag with two (2) large cans of Mountain Dew soda drink was seen on the first shelf of the refrigerator. Staff A stated, That is mine, I forgot to date it. Staff A later revealed that storage of facility food items for resident meals such as butter, eggs and cheese are kept in the cook's refrigerator. An interview was conducted with 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 develop and implement two (#90's and #151) residents' care plans for nebulizer treatment, nebulizer equipment cleaning and tracheostomy care of 33 resident sampled. Findings Included: 1. Review of Resident #90's care plan reflected a focus area of oxygen therapy related to respiratory illness and chronic obstructive pulmonary disease initiated 12/26/19, revised on 6/20/19. Interventions included special equipment oxygen initiated 12/26/18. Give medications as ordered by physician. Monitor/document side effects and effectiveness initiated 12/26/18 revised on 3/20/19. Administer oxygen as ordered initiated on 12/26/18 revised on 3/20/19. During an interview on 11/25/19 at 11:20 a.m. with staff member C, LPN she confirmed she gave Resident #90 her breathing treatment and turned off the machine before she left the room. Staff member C, LPN confirmed she removed the mask from the resident and did not clean the nebulizer before putting the mask back in the bag. Staff member C, stated she listened to the resident's…

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 two (#90 and #151) of three sampled residents, received respiratory care and services related to nebulizer treatments and cleaning for Resident #90 and tracheostomy care including humidified oxygen for Resident #151. Findings Included: 1. During an interview on 11/25/19 at 10:20 a.m. with Resident #90, she confirmed she will give herself breathing treatments and confirmed the nurses do not listen to her lungs or check her oxygen level with each treatment. Resident #90 stated she has been send to the hospital several times for low oxygen levels. Resident #90 stated she was getting this treatment due to getting winded when she transfers from her bed to her wheel chair. During an interview on 11/25/19 at 11:20 a.m. with staff member C, LPN she confirmed she gave Resident #90 her breathing treatment and turned off the machine before she left the room. Staff member C, LPN confirmed she removed the mask from the resident and did not clean…

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.