Bayshore Pointe Nursing and Rehab Center

Inspectors wroteBased on observations, interview and record review, the facility failed to protect the resident's right to be treated with dignity related to unauthorized video recording in the resident's room for two residents (#8 and #9) out of two residents reviewed and failed to ensure timely incontinence care for one resident (#7) out of seven residents observed.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses for eight residents (#28, #1, #46, #33, #57, #47, #40, and #506) out of 22 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure timely identification of a facility acquired pressure ulcer for one resident (#67) out of two residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide enteral nutrition per physician orders for three residents (#52, #101, and #14) out of six residents with gastrostomy tubes.

Inspectors wrote2. On 9/9/24 at 11:28 a.m. an observation of Resident #14 revealed Staff E, LPN and Staff F, LPN/Unit Manager (UM) entered the room to observe the resident. Resident #14 had feces on his face, arms, and bed linens. Observations revealed Staff E, LPN put on PPE to assist with cleaning and changing the resident. Staff F, LPN/UM left the room to retrieve clean linens. Prior to the staff closing the door, to provide privacy while changing the resident, an observation revealed a pole and pump for the tube feeding, however, there was no formula hanging, (Photographic Evidence Obtained). At the time of the observation, Staff E, LPN stated the resident has a gastrostomy (G-tube) tube. On 9/9/24 at 2:39 p.m. an observation of Resident #14 revealed a bottle of Glucerna 1.5 was hanging and running at 72 milliliters per hour (ml/hr). [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure: 1. food was properly stored to include labeling and dating, 2. food was handled appropriately to include glove use; and 3. clean kitchen and beverage items were free from possible contamination, in accordance with professional standards for food service in one of one kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective infection control program, related to not ensuring staff were donning personal protective equipment (PPE) before entering the rooms of residents with contact precaution signage on the door, for one (#7) of five residents sampled on transmission-based precautions. The facility did not offer hand hygiene to residents prior to lunch service for two (9/09 and 9/11/2024) out of two days observed on the second floor and third floor main dining. The facility did not ensure appropriate contact isolation was initiated for one resident (#84) while awaiting Clostridium difficile (CDiff) results, and the facility did not ensure appropriate hand hygiene during medication administration for one resident (#87) out of five residents observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two resident rooms (203 and 207) were maintained in a sanitary manner in one hall (Hall 200) of two halls observed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide appropriate assistance for a resident (#52) of six residents sampled for limited range of motion (ROM) related to the application of physician ordered orthotic devices.

Inspectors wroteBased on interviews, observations, and record review the facility did not ensure a post dialysis assessment was completed for one resident (#40) out of one sampled resident.

Inspectors wrote2. An observation and interview with Resident #9 on 09/11/24 at 10:10 a.m. revealed unsecured medications on Resident #9's bedside furniture including Neosporin and sore throat spray. She stated she uses it from time to time. A review of Resident #9's most recent Quarterly Minimum Data Set, dated [DATE], in Section C-Cognitive Patterns, showed a Brief Interview for Mental Status score of 15 indicating she is cognitively intact. A review of Resident #9's September 2024 physician orders revealed there was no order for throat spray or Neosporin and was silent for an order of self-administration of medication. A review of Resident #9 active care plans revealed no care plan indicating self-administration of medication was in place. An interview was conducted with Staff E, LPN on 09/11/24 at 10:20 a.m. [...]

Inspectors wroteBased on observations, interviews and record review the facility did not ensure the physician was promptly notified of a positive lab result for an infection for one resident (#101) out of eight residents sampled.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure dental services were provided for one resident (#77) of one sampled resident.

Inspectors wroteBased on interviews, and record review the facility failed to ensure appropriate placement was arranged prior to discharge for one resident (#5) out of two residents sampled for discharge.

Inspectors wroteBased on interviews and record review the facility failed to ensure medications were administered as ordered for one resident (#3) out of two residents reviewed for medication administration.

Inspectors wroteBased on observation, resident and staff interview, facility menu review and meal substitution log review, the facility failed to follow the planned menus. This has the potential to affect 80 of 85 residents who consume food in the facility, including one resident (#46) and occurred for 3 of 3 meals observed during the survey.

Inspectors wroteBased on meal observations, test tray observations, resident interviews and record reviews, the facility failed to provide resident meals that were palatable, attractive, and/or at an appetizing temperature for eight residents (#39, #46, #65, #77, #86, #137, #6 and #240) out of eight residents observed at the meal or interviewed about the facility food.

Inspectors wroteBased on observation, resident and staff interview, and menu review, the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences and/or appealing options of foods with similar nutritive value to residents who had requested a different meal choice. This affected four residents (#37, #77, #86, and #137) out of 38 sampled residents.

Inspectors wroteBased on observation, staff interview, and review of cleaning schedules and policies, the facility failed to ensure two Time-Temperature Control for Safety (TCS) foods were not stored too long and that preparation and serving equipment was maintained in clean condition.

Inspectors wroteBased on observations and interviews, the facility failed to treat each resident with respect and dignity, as evidenced by disorganization of their meal service so that residents sitting together at the same table did not receive their meals at the same time, and residents needing assistance were not provided with assistance. This affected three randomly observed residents and Resident #54 in two different dining rooms (main and 3rd floor restorative) of three dining rooms at lunch on 06/20/22.

Inspectors wroteBased on medical record reviews, review of the Advanced Directive audit and review of the facility policy on Advanced Directives, and interviews with facility staff, the facility failed to ensure there was a physician's order for the code status of Do Not Resuscitate (DNR) and failed to ensure the DNR code status was reflected in the electronic medical record for two residents (#42 and #49) out of 27 residents reviewed in the initial pool.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (#22) out of 27 residents reviewed in the initial pool, received the necessary incontinence care to maintain personal hygiene.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure there were no significant medication errors related to administration of insulin via an insulin pen for one resident (#32) out of one resident observed and out of eleven residents in the facility using insulin pens.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control practices related to include hand hygiene and the cleaning and disinfection of a glucometer for one (Resident #68) of three sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure behavioral monitoring for psychotropic medications was consistently documented for two residents (#25 and #240) of five residents reviewed, 2) obtain and consistently complete consents for use of psychotropic medications for four residents (#25, #240, #71 and #39) of five residents reviewed, and 3) perform blood glucose monitoring for one resident (#25) receiving insulin of five residents reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure there was a physician order for the code status of Do Not Resuscitate (DNR), and that the DNR code status was accurate on the electronic medical record, or that a care plan was in place for the Advance Directives for one resident (Resident #63) out of the sampled thirty-two residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement the care plan related to a wander/elopement alarm for one resident (Resident #71) out of the total sample of thirty-two residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure treatment and care in accordance with professional standards of practice for one resident (Resident #71), by failing to notify the physician of elevated glucose levels as ordered by the physician, out of the total sample of thirty-two residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide ordered medications in a timely manner to one resident (#240) of 32 sampled residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure expired medications were removed from one medication cart (3rd floor back hall) out of three medication carts observed, and one medication storage room (3rd floor unit) out of one medication storage room observed.

Inspectors wroteBased on interviews and record review, the facility failed to implement the antibiotic stewardship program by not ensuring antibiotics were given appropriately to one resident (#244) of a total of 32 sampled residents.