Bailey Creek Health and Rehab

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to update the Care Plans for two (Resident #54 and Resident #99) of four residents reviewed.

Inspectors wroteBased on record review, observation, interview, facility document review, and facility policy review, it was determined that the facility failed to initiate and follow Enhanced Barrier Precautions (EBP) for one (Resident #75) of three residents observed for infection control.

Inspectors wroteBased on record review, interview, facility document review, observation, and facility policy review, the facility failed to ensure that physician orders were followed for two (Resident #1 and Resident #4) of two residents reviewed for dressing changes and to ensure one resident (Resident #1) received indwelling catheter care, as ordered.

Inspectors wroteBased on record review, observations, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between glove changes, a Peripherally Inserted Central Catheter (PICC) access was cleaned according to industry standards, and a PICC line dressing was intact prior to accessing the hub for one (Resident #4) of one resident reviewed for infection control practices during PICC access.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the ice scoop holder was maintained in clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the freezer were sealed to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to prevent potential cross contamination of food and clean dishes for residents who received meals from 1 of 1 kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure all cleaning cart doors locked to ensure residents could not access cleaning supplies and chemicals from the unlocked carts to prevent injuries. The facility failed to identify and ensure sharp, jagged plastic from a busted air conditioner frame was repaired to prevent accidents or injuries to 1 (Resident #17) sampled resident reviewed for accidents or injuries.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were appropriately stored behind a lock on the treatment cart to prevent misappropriation of resident medications. The facility failed to ensure medication was stored behind a locked door, and medications were not left at the bedside for 2 (Resident #61, and Resident #375) sampled residents reviewed for medication stored at the bedside.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. This failed practice had the potential to affect 5 residents on pureed diets, 20 residents who received mechanical soft diets and 47 residents on regular diets from the kitchen, according to the list provided by the Registered Dietitian on 9/5/2024 (total Census 74).

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure dementia training was provided for nursing aide staff to meet the needs of the facilities population. This failed practice had the potential to affect 18 (Residents #3, #17, #19, #21, #30, #31, #33, #40, #47, #49, #55, #60, #61, #64, #65, #176, #177, #375) sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure the privacy and dignity of 1 (Resident #33) sampled resident. This failed practice had the potential to affect 2 (Resident #33, Resident #49) sampled residents reviewed for privacy.

Inspectors wroteBased on record review and interview, the facility failed to ensure written notification of the reason for transfer/discharge to the hospital was provided to the resident and/or resident's representative to protect the resident rights for 1 (Resident #31) of 2 sampled residents who were reviewed for hospitalization.

Inspectors wroteResident #31 Hospitalization Based on record review and interview, the facility failed to ensure written notification of the bed hold policy to include the reserve bed payment was provided to the resident and/or resident's representative to protect the resident rights for 1 (Resident #31) of 2 (R#31 and R#74) sampled residents who were reviewed for hospitalization.

Inspectors wroteFACILITY Infection Control Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure staff applied appropriate personal protective equipment (PPE) such as isolation gowns when interacting with 1 (Resident #1) of 2 sampled residents reviewed for Enhanced Barrier Precautions. This deficient practice had the potential to affect all residents who are on Enhanced Barrier Precautions. 1. Quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 6/27/24 indicated Resident # 1 with diagnoses of Gastrostomy status, Hemiplegia and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Aphasia. MDS indicated resident has a Gastrostomy tube and a BIMS score of 3 (0-7 suggests severe cognitive impairment) a. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated for 3 (Residents #2, #3, and #4) of 5 case mix residents. This failed practice placed all 62 residents at risk for verbal abuse.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from accidents during resident care by allowing staff to not follow residents care plan. This failed practice had the potential to affect 1 resident that had a fall in the month of November during resident care who resided on the 100 Hall as documented on a list provided by the Administrator on 1/3/2024 at 11:41 am.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, safe homelike environment for residents who reside in rooms 303, 304, 305, 310 and 316.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fingernails were clean, groomed, and free from jagged edges to promote good personal hygiene and grooming for 2 (Resident #8 and #26) of 14 (Resident #4, #5, #8, #11, #17,#20, #21, #24, #26, #37, #39, #43, #54, and #57) sampled residents that were dependent on staff for fingernail care.

Inspectors wroteBased on Observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for oxygen use for one (R#5) of 5 (R#1, #5, #21, #24 and #37) sampled residents who had physicians orders for oxygen.

Inspectors wroteBased on observations, interview, and record review the facility failed to post signage indicating oxygen in use for one (R#5) of five (R#1, #5, #21, #24 and #37) sampled residents who had physician order for oxygen.