Barbour Court Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of medications (Resident #8, Resident #4, and Resident #5) and Pneumococcal Vaccine (Resident #18). This was for 4 of 28 residents whose MDS assessments were reviewed.Findings included:a. Resident #8 was admitted to the facility on [DATE].Resident #8's physician orders included Novolog (a rapid acting insulin) injection solution 100 units/milliliter inject 10 units subcutaneously (beneath the skin) with meals. Hold for blood sugar less than 150 with a start date of 3/18/25.Resident #8's December 2025 Medication Administration Record (MAR) noted Novolog was administered subcutaneously to him on 12/25/25 at 11:30 AM, on 12/26/25 at 6:30 AM, on 12/27/25 at 6:30 AM, 11:30 AM, and 5:30 PM, on 12/28/25 at 6:30 AM and 11:30 AM, on 12/29/25 at 6:30 AM and 5:30 PM, on 12/30/25 at 11:30 AM and 5:30 PM, and on 12/31/25 at 6:30 AM and 5:30 PM.Resident #8's quarterly MDS assessment dated…

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 with staff and the Nurse Practitioner (NP), the facility failed to ensure the resident's need for insulin (a hormone that regulates blood sugar levels) administration in accordance with the parameters provided by the physician before administering the insulin. This deficient practice affected 1 of 5 residents (Resident #8) reviewed for unnecessary medications.Findings included:Resident #8 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM II).A current active physician's order for Resident #8 with a start date of 3/18/25 revealed Novolog injection solution (a type of fast acting insulin)100 units per milliliter inject 10 units subcutaneously (SQ is beneath the skin) with meals and to hold (do not give) for blood sugar (BS) less than 150 (a normal adult BS before eating is between 70 to 99.A review of Resident #8's December 2025 Medication Administration Record (MAR) revealed documentation by Nurse #1 indicating that…

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 b. Review of Resident #18's medical record revealed the Resident was readmitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, and cardiovascular disease. The review revealed a full code status was care planned on 5/20/23. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. c. Review of Resident #51's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and hypertension. The review revealed a full code Physician order dated 11/5/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #84's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and diabetes. 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 2. Resident #100 was admitted to the facility on [DATE]. A review of Resident #100's care plan revealed it was last updated on 10/6/24. A review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. On 11/12/24 at 1:35 PM an interview with Resident #100 indicated he did not recall ever being invited to attend a care plan meeting. He stated he would like to be invited to attend. On 11/13/24 a review of Resident #100's medical record did not reveal any documentation that a care plan meeting was conducted since Resident #100's admission to the facility. On 11/13/24 at 11:03 AM an interview with MDS Nurse #1 indicated Resident #100's Social Worker (SW) was responsible for sending the invitations and for arranging Resident #100's care plan meetings. She reported a care plan schedule calendar was generated based on the MDS assessment dates and provided to the SW. She further indicated Resident #100 would have been scheduled for a care plan meeting…

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 resident, staff, and Medical Director interviews the facility failed to protect a resident's right to be free from the misappropriation of controlled medication for 1 of 2 residents (Resident #40) reviewed for misappropriation. Findings included: A review of the facility's policy titled Abuse, Neglect, or Misappropriation of Resident Property dated last revised on 3/10/2017 revealed in part The facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation or misappropriation of property. The facility will do whatever is in it's control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Resident #40 was admitted to the facility on [DATE] with a diagnosis of chronic pain. A physician's order for Resident #40 dated 5/17/24 indicated to administer oxycodone (a narcotic pain medication) 10 milligrams (mg)/acetaminophen (a non-narcotic pain medication) 325 mg one tablet by…

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, resident and staff interviews the facility failed to provide nail care for a dependent resident for 1 of 7 residents reviewed for activities of daily living (ADL) (Resident #18). The findings included: Resident #18 was readmitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, and early onset cerebellar ataxia (lack of voluntary coordination of muscle movement beginning at the cerebellum of the brain). A review of a care plan dated 5/5/22 revealed Resident #18 had activities of daily living and personal care deficit with interventions which included Resident #18 was totally dependent on staff for bathing and preferred bed baths. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired and was not coded for rejection of care. Resident #18 required total dependence with bathing and grooming An observation and interview with Resident #18 were conducted on 11/12/24 at 11:54 AM.…

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 discard expired medication that remained on the medication cart available for use. This was for 1 of 4 medication carts (Upper 300 Hall) reviewed for medication storage. Findings included: On 11/14/24 at 4:11 PM an observation of the Upper 300 Hall medication cart and interview with the Unit Manager occurred. The observation of the medication cart revealed an opened 355 milliliter (ml) bottle of Antacid Liquid medication with an expiration date of July 2024. The bottle contained liquid medication. An interview with the Unit Manager at that time indicated there was liquid medication remaining in the bottle. She reported this Antacid Liquid medication was expired and should not have been on the medication cart available for use. She stated she checked this medication cart weekly for expired medications and had last checked it on 11/11/24 or 11/12/24. She went on to say she must have missed this bottle. On 11/15/24 at 1:18 PM an interview with the Director of Nursing (DON) indicated the medication carts were monitored…

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 staff interviews the facility failed to ensure advanced directive information matched throughout the medical record for 1 of 1 resident (Resident #67) reviewed for advanced directives. Findings included: Resident #67 was admitted to the facility on [DATE]. Resident #67's electronic medical record revealed an active physician's order dated [DATE] that read DNR (Do Not Resuscitate). A review of Resident #67's paper medical chart revealed there was no advanced direction information in the paper medical chart. The facility did not have an additional notebook with resident DNRs at the nursing station. Resident #67's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact. An interview was conducted on [DATE] at 8:38 A.M. with Resident #67. Resident #67 indicated she was unable to recall when, but she told someone at the facility she did not want her chest pumped or someone to breathe for her if her body stopped working. She stated she was unable…

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 staff interviews, the facility failed to ensure a resident with a mental disorder had received a Preadmission Screening and Resident Review (PASRR) prior to admission to the facility for 1 of 4 residents reviewed for PASRR (Resident #100). Findings included: Resident #100 was admitted to the facility on [DATE] from another nursing home with a diagnosis of bipolar disorder. Resident #100 was discharged to the hospital on 3/18/2023 and was readmitted on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was not considered by the state Level II PASRR process to have a serious mental illness. There were no Level II PASRR conditions marked for serious mental illness. The MDS indicated Resident #100's diagnoses included bipolar disorder. Resident #100 was noted as receiving an antipsychotic (treatment for mental health conditions) medication daily. Resident #100's care plan dated 4/22/2023 included a focus for the use of psychotropic drugs for…

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 staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of an indwelling urinary catheter for elimination for 1 of 2 residents reviewed for urinary catheters (Resident #240). Findings included: Resident #240 was admitted to the facility on [DATE] and diagnoses included fracture right femur. The nursing admission assessment dated [DATE] at 10:37 p.m. recorded Resident #240's indwelling urinary catheter was draining clear yellow urine. Physician orders dated 2/2/2023 included providing urinary catheter care with soap and water every shift. Physician progress notes dated 2/3/2023 recorded use of the indwelling urinary catheter was due to Resident #240's inability to sit up and use a urinal after surgery of to the right femur. The baseline care plan dated 2/3/2023 for Resident #240 did not address the use of an indwelling catheter for urine elimination. On 9/01/2023 at 9:30 a.m. in an interview with Nurse #2,…

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, observations and staff interviews, the facility failed to discard a resident's unlabeled opened Humalog insulin vial from 1 of 3 medication storage rooms observed (Specialized Programming for Alzheimer's Related Care [SPARC] unit). Findings included: Resident #119 was admitted to the facility on [DATE]. Physician orders dated 7/25/2023 included an order for Humalog solution 100unit/ml (Insulin Lispro (Human) inject as per sliding scale subcutaneously before meals for diabetes mellitus: if 0-150=0 units, 151-200= 2 units, 251-250=4 units, 251-300=6 units, 301-350=8 units, 351-400 =10 units; 401+ =12 units or above. Call MD if patient symptomatic. The order stated to discard the medication 28 days after opening and to check the expiration date. The order for Humalog insulin was started on 7/25/23 and was discontinued on 7/31/23. A review of Resident #119's Medication Administration Record for July 2023 indicated blood glucose monitoring was conducted three times a day and blood glucose…

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, observations, resident interivew and staff interviews, the facility failed to honor food preferences for 1 of 2 residents reviewed for food preferences (Resident #100). Findings included: Resident #100 was admitted to the facility on [DATE]. Resident #100's care plan dated 4/25/2023 included a focus for nutrition with actual weight loss due to cardiac disease. Interventions included providing diet as ordered and referencing dietician evaluations and recommendations. Physician orders dated 5/2/2023 included an order for a regular texture no added salt diet and to encourage fluids and offered hydration periodically every day for hydration. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was moderately cognitively impaired and independently fed herself after the meal tray was set up. Dietary documentation dated 7/18/2023 indicated Resident #100 was receiving a regular textured no added salt diet with thin liquids and was consuming 50-100% on her dietary…

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 record review, observations, resident interview and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 4/8/2022. This was for two recited deficiencies on the current recertification and complaint investigation survey of 9/01/23. The deficiencies included Baseline Care Plan (F655) and Resident Allergies, Preferences and Substitutes (F806). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross-referenced to: F-655 Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of an indwelling urinary catheter for elimination for 1 of 2 residents reviewed for urinary catheters (Resident #240). During the recertification and complaint survey of…

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.