Baywind Village Skilled Nursing & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, dispensing and administering of controlled medications and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 2 of 3 residents (Residents #1 and Resident # 2) reviewed for pharmacy services.Med Aide B signed out a controlled pain medication from the narcotic control book, did not sign off on the Electronic Medical Administration Record that a controlled medication was administered for Resident #1. LVN A signed out a controlled antianxiety medication from the narcotic control book, did not sign off on the Electronic Medical Administration Record that a controlled medication was administered for Resident #2. These failures could place residents at risk of not receiving their medication or receiving double dosage of controlled medications and drug diversion.Findings:Record…

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 provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 1 of 3 residents (Residents #1) reviewed for pharmacy services. -LVN V and RN E, who signed out control pain medication from the control book, did not sign off on the TAR or MAR that control medications were administered for Resident #1. This failure could place residents at risk of not receiving their medication and drug diversion. Record review of Resident #1's face sheet dated 11/05/25 revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included displacement fracture of base of neck of right femur, subsequent encounter for closed fracture without routine healing (received active treatment for 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 interviews and record review, the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 2 of 4 (Resident #76 and Resident #293) residents reviewed for colostomies (surgical opening in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). The facility failed to ensure training, care and documentation was consistent for Resident #76 and Resident #293 as bowel movements were not consistently documented, a colostomy was documented as an ileostomy/urostomy and colostomies were not consistently emptied. The failure could place residents at risk of complications related to a colostomy and emotional distress. Resident #76 and #293 experienced discomfort, anxiety, embarrassment and refused to take medications to prevent constipation as a result of the failure. Findings included: Record review of Resident #76's face sheet dated [DATE], revealed 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 observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1(Resident # 64) of 18 residents reviewed for care plan. Resident #64's care plan was not revised to reflect her D\C use of catheter on 04/20/25. This failure could place residents at risk of not receiving needed services and care to improve their health. Findings Include: Resident #64: Record review or Resident #64's face sheet, dated 05/05/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included essential hypertension (high blood pressure), type 2 diabetes mellitus without complications, lack of coordination, and muscle weakness. Record review of Resident #64's MDS, dated [DATE], revealed Resident #64's BIMS score was blank 15 out of 15 which indicated she was cognitively intact. Review of section H Bladder and Bowel was checked as having an indwelling catheter. Record review of Resident…

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 notify the resident representative when the resident experienced a significant change in condition for 1 (CR #1) of 5 residents reviewed for resident rights. The facility failed to notify CR #1's Responsible Party when she had a hypotensive event and refused to go to the hospital. This failure could result in the resident representative not being aware of conditions that may require them to make medical decisions. Findings included: Record review of CR #'1s face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: fracture of unspecified carpal bone right wrist, hypo-osmolality and hyponatremia (a condition where the body retains water and sodium levels in blood are lower than normal), and hypertension. The family member was listed as the Responsible Party and Power of Attorney-care, care conference person, and HIPPA for CR #1. Record review of CR #1's initial MDS assessment dated [DATE] revealed CR #1 had…

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 provide and document adequate preparation to residents to ensure safe and orderly transfer or discharge from the facility, for 1 (CR #2) of 3 residents reviewed for transfer/discharge. The facility failed to ensure CR #2 was discharged with Home Health Services in place. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services. Findings included: Record review of CR #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: asthma with acute exacerbation, sepsis, hyperlipidemia, local infection of the skin and subcutaneous tissue, xerosis cutis (abnormally dry skin), Stage 4 pressure ulcer of sacral region, chronic gout, muscle weakness, neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), urinary tract infection, cognitive communication deficit, anxiety disorder,…

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 reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 18 residents (CR #1) reviewed for resident rights. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from CR #1 prior to administering Zoloft, an antidepressant used to treat depression. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include : Record review of CR #1's electronic face sheet revealed an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included adjustment disorder…

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 provide dignity and respect for 1 of 9 (Resident #1) residents observed for dignity in that: -The facility failed to have a privacy curtain in Resident #1's room during wound dressing change. This failure could affect resident (s) that required assistance with care at risk for embarrassment and lower self-esteem. Findings: Record review of Resident #1's face sheet revealed an 83year old male admitted to the NF on 04/25/2023 with the following diagnoses: acute cystitis (inflammation of the bladder) without hematuria (blood in urine), obesity, hypertension (high blood pressure), atherosclerosis (build up cholesterol/fat in the artery causing obstruction of blood), coronary artery bypass, pneumonia (infection in the lung), gastro-esophageal reflux disease (acid from the stomach that backs up in the throat), and low back pain. Record review of Resident #1's MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating cognition…

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 maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections for 1 of 9 (Resident #1) residents reviewed for infection control in that: -LVN A failed to practice infection control when changing Resident #1's dressing to the sacrum. This failure placed resident at risk for cross contamination and spread of infections and hospitalization. Findings : Record review of Resident #1's face sheet revealed an 83year old male admitted to the NF on 04/25/2023 with the following diagnoses: acute cystitis (inflammation of the bladder) without hematuria (blood in urine), obesity, hypertension (high blood pressure), atherosclerosis (build up cholesterol/fat in the artery causing obstruction of blood), coronary artery bypass, pneumonia (infection in the lung), gastro-esophageal reflux disease (acid from the stomach that backs up in the throat), and low back pain.…

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 did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #1 and #3) of 3 residents reviewed for infection control. -CNA-A did not wash or sanitize her hands in between assisting multiple residents with feeding. This failure could place residents who required feeding assistance with cross contamination and infection. Findings include: Observation on 01/13/2023 at 12:39pm of CNA-A in the dining area assisting residents with feeding. CNA-A was observed moving from one resident's table to another resident's table to assist with feeding. CNA-A was not observed washing or sanitizing her hands in between assisting residents. Interview on 01/13/2023 with CNA-A at 2:27pm, she stated she has been employed at the facility for about 3-4 months and she was still in training. CNA-A stated hand hygiene was supposed to be performed before entering a resident's room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the facility provided pharmaceutical services (including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 5 residents (Resident #127) reviewed for pharmacy services. -The facility failed to ensure that Resident #127's Retacrit injection, a medication used to treat anemia caused by chronic kidney disease, was received from the pharmacy. -The facility failed to ensure that Resident #127's Retacrit injection, a medication use to treat anemia caused by chronic kidney disease, was administered per physician order. These failures could place residents whose medications were supervised by the facility at risk of experiencing serious side effects and or adverse reactions from possible interruptions to their medication regimen. Findings Included: Record review of Resident #127's admission record revealed she was a [AGE]…

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, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food service safety, in that: -1 plastic container of expired food was present in the refrigerator. This failure could place residents at risk for cross-contamination and foodborne illnesses. Findings include: Observation of the kitchen on 01/11/2023 at 9:25am, revealed 1 turkey wrap in a clear plastic container dated 01/07/2023 with a use by date of 01/10/2023 in refrigerator. Interview and observation on 01/11/2023 at 9:37am with Dietary Aid A, she stated she had been employed at the facility for 6 years. She stated that the turkey wrap was made on 01/07/2023, and it she should have been thrown out after the use by date on 01/10/2023. She stated that staff check for expired food in the refrigerator twice daily before breakfast meal service and after dinner service. She stated that that the turkey wrap should have been thrown out on 01/10/23 after the dinner service,…

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 dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. Findings include: An observation on 1/11/23 at 9:26 am., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-sized dumpster with garbage inside of it. There were 2 lids on the dumpster, the right lid was open. Interview and observation on 1/11/23 at 9:26 am, with Dietary Aide A, she said that she did not know that the dumpster lids must always be closed, she said that she thought the regulation to do so would be to avoid infestation of pest. Interview on 1/11/23 at 9:50 am with the Dietary Manager/Dietician she said that the dumpsters outside are to be kept closed to prevent rodents, pests, and insects out of the dumpster and from entering the facility. 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 observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #127) reviewed for resident records, in that: -Resident #127's progress notes were not complete or accurate regarding her Retacrit medication. This deficient practice placed residents who receive medications from facility staff at risk for less than therapeutic benefits and/or not receiving ordered medications due to incomplete documentation. Findings include: Record review of Resident #127's admission record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with end stage renal (kidney) disease (a condition in which a person's kidneys cease functioning on a permanent basis leading to the need for regular long-term dialysis or kidney transplant to maintain life), dialysis (a procedure to remove waste products and excessive…

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.