Batavia Nursing Care Center

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered per physician orders. This affected one (#78) of five residents reviewed for medication administration. The facility census was 97.Findings include:Review of Resident #78's medical record revealed an admission date of 04/29/21. Diagnoses included low back pain and chronic pain. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/26, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #78 received a scheduled pain medication regimen. Review of the physician orders revealed Resident #78 had an order dated 11/21/24 for a lidocaine external patch four percent (%), apply to sacrum topically one time a day for pain/discomfort, 12 hours on and 12 hours off, and remove per schedule. Review of the Medication Administration Record (MAR) from 03/01/26 to 03/31/26 revealed the transcription…

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, staff interview, and medical record review, the facility failed to ensure accurate medical records. This affected one (#78) of five residents reviewed for medication administration. The facility census was 97. Findings include: Review of Resident #78's medical record revealed an admission date of 04/29/21. Diagnoses included low back pain and chronic pain. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/26, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #78 received a scheduled pain medication regimen. Review of the physician orders revealed Resident #78 had an order dated 11/21/24 for a lidocaine external patch four percent (%), apply to sacrum topically one time a day for pain/discomfort, 12 hours on and 12 hours off, and remove per schedule. Review of the Medication Administration Record (MAR) from 03/01/26 to 03/31/26 revealed the transcription of a physician order dated 11/22/24 to apply a…

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 staff interview, observation, record review, and facility policy review, the facility failed to provide care for a peripherally inserted central catheter (PICC) consistent with standards of practice when they did have physician orders for the dressing change of the PICC line, did not flush the catheter per order, and did not change the PICC line dressings weekly. This affected one, (Resident #59) of three residents reviewed for intravenous lines. The facility census was 92. Finding include: Record review for Resident #59 revealed an admission date of 04/13/22 with pertinent diagnoses of cerebral infarction due to thrombosis, dependence on respirator, tracheostomy status, gastrostomy status, persistent vegetative state, chronic respiratory failure with hypoxia, thrombocytopenia, pulmonary embolism, anemia, hypertension, retention of urine, and hirsutism. Review of the 01/10/25 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was in a persistent vegetative state and was dependent for all activities of daily living. The Resident used a ventilator 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.

Based on observation, medical record review, staff interview, review of a job description, and facility policy review, the facility failed to maintain infection control practices when handling dirty linens for one (Hall K) of seven halls observed and failed to use proper hand hygiene during incontinence care. This had the potential to affected 16 (#2, #5, #6, #8, #10, #17, #25, #29, #42, #44, #47, #57, #65, #68, #70, and #85) residents who resided on Hall K and one (#83) of two residents observed during incontinence care. The census was 96. Findings included: 1. On 09/23/24 at 10:15 A.M., an observation on Hall K revealed an open resident's door with dirty linens on the floor. State Tested Nurse Aide (STNA) #1 was observed throwing linens on the floor and then was observed picking up the linens without wearing gloves and placing them into a bag. During an interview on 09/23/24 at 10:20 A.M., STNA #1 stated she should not have thrown anything on the floor and should have worn gloves when she put the dirty linens in the bag. STNA #1 stated she had infection control education during…

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, medical record review, staff interview, and facility policy review, the facility failed to ensure dignity was maintained for one (#73) of four residents observed during care. The census was 96. Findings included: Review of an admission record indicated the facility admitted Resident #73 on 01/25/23. The resident had a medical history that included diagnoses of traumatic brain injury, chronic respiratory failure with hypoxia, and a tracheostomy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/02/24, revealed Resident #73 had severe impairment in cognitive skills for daily decision-making per a staff assessment of mental status (SAMS). The MDS assessment indicated the resident was dependent on staff with all activities of daily living (ADLs) and required tracheostomy care. Review of Resident #73's care plan, included a focus area initiated 05/28/21, that indicated the resident had altered health maintenance related to a progressive physical and mental status due to a motor vehicle accident resulting in a…

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, staff interview, and policy review, the facility failed to ensure medications were stored with accurate labeling for safe administration when staff prepped medications and took the medications out of their original packaging. This affected two (#57 and #59) out of four residents observed for medication administration. The facility census was 93. Findings included: 1. Review of the clinical record revealed Resident #59 readmitted to the facility on [DATE]. His diagnoses included but were not limited to paraplegia, urinary tract infection, overactive bladder, neuromuscular dysfunction of the bladder, constipation, anemia, bladder disorder, and chronic pain syndrome. Review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Observation on 12/28/23 at 5:45 A.M. of Licensed Practical Nurse (LPN) #156 pulling medication for Resident #59 revealed the resident's medications were observed to be in a foam cup with no name or label. 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 observations, staff interviews, medical record reviews, review of facility policies, and review of the Centers for Disease Control (CDC) prevention online guidance, the facility failed to ensure appropriate isolation precautions and use of Personal Protective Equipment (PPE) were implemented and failed to ensure staff performed adequate hand hygiene when completing care hygienic care. This affected three (#7, #42 and #89) of three residents reviewed for infection control and the potential to affect all residents in the facility. The facility census was 101. Findings include: 1. Review of Resident #7's medical record review revealed an admission date of 05/20/22, with diagnoses including anoxic brain damage, acute and chronic respiratory failure, mild protein calorie malnutrition, epilepsy, tracheotomy status, and need for assistance with personal care. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/21/22, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility 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, staff interview and policy review, the facility failed to ensure food storage was maintained in a clean manner to prevent potential food contamination or food borne illness. This had the potential to affect 50 of 50 resident who reside on the affected units. The facility census was 101. Findings include: Observation on 10/26/22 from 9:50 A.M. through 10:15 A.M., revealed the in the E/F Unit resident refrigerator: the outside of the freezer casket pull away from the top side and corner edge of the door exposing debris; inside the freezer, there was a built up of ice where the door closed, preventing the door from completely shutting and making a complete seal; there was and outside handle missing from the refrigerator door exposing two holes in the door; two large, insulated lunch containers with no name or date; two open containers of fluids with no open date and opened and partially served ice cream cake in freezer with no open date. In the J/K Unit resident refrigerator an opened and partially served resident identified gallon of milk with expiration date…

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, staff interview and policy review, the facility failed to respond timely to pharmacy recommendations after being acknowledge by the physician. This affected one (#96) of five residents reviewed for pharmacy recommendations. The total facility census was 101. Findings include: Review of Resident #96's medical record revealed an admission date of 11/15/19, with diagnoses including: diabetes, quadriplegia, chronic ulcer in foot, pressure hypertension, open wound, colostomy, suprapubic catheter, oxygen via nasal cannula and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was receiving the medication, Midodrine HCL tablet 10 milligrams every eight hours for hypotension. Review of the pharmacy recommendation dated 03/15/22, revealed the pharmacist recommended the Midodrine order should include parameters to ensure it is only given when clinically appropriate. The physician signed the pharmacy recommendation on…

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.