Bay Pointe Rehabilitation and Nursing

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a Medication Regimen Review (MRR) policy that included required time frames for pharmacist's review and physician's response to the pharmacist's recommendations, potentially affecting all residents but specifically for five of 33 residents in the survey sample; Residents #15, #69, #16, #67 and #39.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for five out of 33 residents in the survey sample, Residents ##11, #62, #57, #32 and #111.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for seven of 33 residents in the survey sample, Residents #68, #89, #39, #22, #62, #25 and #101.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to provide food in a palatable and appetizing manner from one of one facility kitchens.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on observation, resident interview, facility document review, and clinical record review, the facility staff failed to maintain a resident's dignity for one of 33 residents in the survey sample, Resident #6.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a clean, comfortable, and homelike environment for two of 33 residents in the survey sample, Residents #32 and #106.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide written notification to the Office of the State Long-Term Care Ombudsman of a hospital transfer for one of 33 residents in the survey sample; Resident #67.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of 33 residents in the survey sample, Residents #7, #68 and #89.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice for medication administration for one of 33 residents in the survey sample, Resident #89.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 33 residents in the survey sample, Resident #68.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to store respiratory equipment in a sanitary manner for two of 33 residents

Inspectors wroteBased on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 33 residents in the survey sample, Resident #22.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of a current bed rail assessment and consent, for one of 33 residents in the survey sample, Residents #109.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services for one of 33 residents in the survey sample, Resident #7.

Inspectors wroteBased on clinical record review, staff interview and facility document review it was determined that the facility staff failed to evidence monitoring of psychotropic medication for one of 33 residents in the survey sample, Resident #39.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to securely store a medication for one of 33 residents in the survey sample, Resident #52.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a current dialysis contract for two of 33 residents in the survey sample, Residents #52 and #22.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 33 residents in the survey sample, Resident #7.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to post daily staffing for one of three days reviewed.

Inspectors wroteBased on observation, record review, interviews, policy review, review of the disinfectant label, review of manufacturer's guidelines, and review of Centers for Disease Control and Prevention (CDC) guidelines for COVID-19, the facility failed to: 1. ensure that three of four Licensed Practical Nurses (LPN) (LPN 1, LPN2, and LPN4) on Unit 2 cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the EPA-approved disinfectant's instructions for use when performing fingerstick blood glucose testing (accuchecks) between residents; and 2. ensure that a new agency staff was screened for signs and symptoms of COVID-19 upon entrance to the facility. [...]

Inspectors wroteBased on observation, interviews, and review of facility policies and procedures, the facility failed to ensure a safe and clean environment in 10 of 16 resident rooms on the second-floor east unit. This deficient practice affected 19 of 30 residents on the second-floor east unit.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for five residents (Resident (R)286, R288, R290, R23, and R233) out of a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that one resident's (Resident (R) 233) out of a sample of 21 residents electronic medical record (EMR) was kept from public view.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure one resident (Resident (R) 16) of 21 sampled residents was free from chemical restraints. On 07/16/21 R16 was administered Ativan (an antianxiety medication) via intramuscular (IM) injection for staff convenience.

Inspectors wroteBased on record review and interviews, the facility failed to complete an initial nursing assessment upon admission for one resident (Resident (R) 290) out of 21 sampled residents.

Inspectors wroteBased on record review, interview, and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for restorative nursing services for one resident (Resident (R) 76) in a total sample of 21 residents.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 76) of three residents reviewed for activities out of a total sample of 21 residents was consistently provided activities that supported the physical, mental, and psychosocial needs of the resident.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure that one resident (Resident (R) 76) of two residents reviewed for position and mobility out of a total sample of 21 residents received treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, facility staff failed to provide physician ordered passive (PROM) and splints and/or braces as recommended by therapy.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 15) out of five residents reviewed for accidents was transported in a wheelchair with legrests to prevent injury in a total sample of 21 residents.

Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to ensure one resident (Resident (R) 78) of seven residents reviewed for unnecessary medications had a stop date for a PRN (as needed) antianxiety medication used for seizures.

Inspectors wroteBased on staff interview and employee record review the facility staff failed to verify licensure with the State licensing board prior to hire for 5 nurses and failed to verify certification of nursing assistants with the State nurse aide registry prior to hire for 3 nursing assistants. It was identified during an employee record review that the credentials of a total of 8 licensed and certified nursing staff were not verified prior to hire or verified at all.

Inspectors wrote3. Resident #41's bed remained in the high position during the days of survey. Resident #41 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, congestive heart failure, traumatic brain injury and seizure disorder. Resident #41's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 8-22-18. Resident #41 was coded with a Brief Interview of Mental Status score of 9 out of a possible 15 indicating moderate cognitive impairment. Resident #41 required extensive to total assistance of one to two staff members for bed mobility and bathing and toileting. On 10/24/18 at 9:06 AM Resident #41 was observed in bed: the bed was in high position. The resident had a suction machine at the bedside. On 10/25/18 at 10:27 AM Resident #41 was not in bed as he had been transferred to the hospital. [...]

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a dignified living experience for two residents (Resident #59 and Resident #41) in a survey sample of 33 residents. 1. Resident #59 was not offered a clothing protector during her meals and her clothing became stained with food. 2. Resident #41 had excessive drooling. There was no towel or clothing protector in place and his neck/shoulder was wet with mucus. 3. Residents in the dining room were called Grandma and Grandpa.

Inspectors wroteBased on observation, staff interview, resident interview and clinical record review the facility staff failed to ensure 1 resident (Resident #28) of 33 residents in the survey sample were assessed to self administer medications. For Resident #28, Systane eye drops were observed on the bedside table.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure Advanced Beneficiary notices were provided prior to loss of benefits, for 3 residents (Resident #18, #146, and #147), in a survey sample of 33 residents. The facility staff failed to provide Residents #18, #146, and #147 with written notification prior to their loss of benefits.

Inspectors wroteBased on observation, resident interview and clinical documentation, the facility failed to maintain a clean and homelike environment. Resident #59's room had a sustained strong urine odor.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete a discharge MDS ( Minimum data set) for one resident (Resident # 2 ) in a survey sample of 33 residents. For Resident # 2, the facility staff failed complete a Discharge MDS after discharge on [DATE].

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to Incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident ' s assessment, care planning, and transitions of care for one resident (Resident #12) in a sample of 33 residents. 1. For Resident #12, the facility staff failed to implement the PASARR II recomendations to meet the Resident's intellectual disability (ID) needs.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure the PASARR was completed prior to admission for three residents (Resident #74, #29, #85) in a sample of 33 residents. 1. For Resident #74, the facility staff failed to ensure a PASARR was completed prior to admission. 2. For Resident #29, the facility staff failed to ensure a PASARR was completed prior to admission. 3. For Resident #85, the facility staff failed to ensure a PASARR was completed prior to admission.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for three Residents (Residents #93, #53, #28) of 33 residents in the survey sample. 1. Resident #93's care plan did not include person centered interventions for weight loss. 2. Resident #53's care plan did not include person centered interventions for pressure sores. 3. For Resident #28, a discharge care plan was not included in the comprehensive care plan.

Inspectors wroteBased on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional practice standards for two residents (Residents #53) of the 33 residents in the survey sample. 1a) For Resident #53, the facility staff failed to administer physician ordered treatments. 1b) For Resident #53, the facility staff falsified medication and treatment administration records. 2. For Resident #96, an activities staff without a nursing background completed the baseline care plan

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to develop and implement an effective discharge planning process for two residents (Resident #12, #96) in a sample of 33 residents. 1. For Resident #12, the facility staff failed to implement a timely discharge plan to a facility equipped to meet the Resident's intellectual disability (ID) needs. 2. For Resident #96 the facility staff failed to develop a discharge plan.

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to provide activities appropriate for Resident's age and intellectual disability for one Resident (Resident #12) in a sample of 33 residents.

Inspectors wroteBased on observation, resident interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide treatments, failed to follow doctor's orders, and failed to complete a measurable comprehensive care plan for pressure ulcers for 1 Resident (Resident #53) in a survey sample of 33 residents. For Resident #53, the staff failed to treat 2 pressure ulcers on the Resident's left and right buttocks, failed to follow doctor's orders, and failed to appropriately care plan the Resident's needs.

Inspectors wroteBased on observation, staff interview, facility documentation review and clinical record review the facility staff failed to provide weight loss intervention, and to prevent further significant weight loss for one Residents (Resident #93) of the 33 residents in the survey sample. For Resident #93 the facility staff did not provide weight loss interventions for a Resident with diabetes, and wounds, and failed to intervene during a significant weight loss.

Inspectors wroteBased on observation, resident and staff interview and clinical record review, the facility staff failed to provide pain management for 1 resident (Resident #51) of 33 residents in the survey sample. Resident #51 did not have a standing X Ray as ordered by the pain management clinic.

Inspectors wroteBased on observations, resident interview, staff interview, and clinical record review, the facility staff failed to provide psychotherapy for grief, anxiety, and depression as recommended by the psychiatric nurse practitioner for one Resident (Resident #12) in a sample of 33 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide community living skills, day support and rehabilitation, self-help/personal care skills, a social skills development program, or transportation to specialized services as recommended on the PASARR II for one resident (Resident #12) in a sample of 33 residents.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review the facility staff failed to ensure beverages were served according the plan of care for 1 resident (Resident #14) of 33 residents in the survey sample. Resident #14 was not served honey thickened beverages per the plan of care.

Inspectors wroteBased on observation and staff interview the facility staff failed to ensure an effective infection control program was implemented for 2 residents (Resident's #42 and #17) of 33 residents in the survey sample. 1. For Resident #42, the facility staff: a. touched medications with gloved hands after touching unclean surfaces b. laid the opened Spiriva handihaler on the medication cart with the inside of the inhaler touching the medication cart surface c. took the box of Spiriva capsules and Symbicort inhaler box into the resident room, laying them on the uncleaned bedside table and returning the boxes to the cart drawer. 2. For Resident #17, the facility staff prepared medications in a medication cup, put the medications in her pocket when providing care to another resident, and then administered the medications that had been stored in her pocket.