Bayside of Poquoson Health and Rehab

Inspectors wroteBased on observations and staff interviews the facility staff failed to ensure resident equipment was kept clean for 1 of 12 residents (Resident #7), in the survey sample.

Inspectors wroteBased on observations, family interview, and staff interviews, the facility staff failed to develop person-centerd care plan for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide hygiene care for dependent residents for 2 of 12 residents (Residents #2 and #6), in the survey sample.

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while utilizing an indwelling catheter for 1 of 12 residents (Resident #4), in the survey sample.

Inspectors wroteBased on observations, resident interview, and clinical record review, the facility staff failed to necessary respiratory care and services for 1 of 12 residents (Resident #6), in the survey sample.

Inspectors wroteBased on observations and staff interview the facility staff failed to secure resident medications on 3/27/25.

Inspectors wroteBased on family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to assess and monitor a surgical wound on a resident's right breast after a breast biopsy was completed; which contributed to the resident becoming septic and hospitalized for 1 of 12 residents (Resident #1), in the survey sample.

Inspectors wroteBased on observations, family interview, and staff interviews, the facility staff failed to properly care for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in the survey sample.

Inspectors wroteBased on staff interview, clinical record review, and in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for 1 of 12 residents in the survey sample

Inspectors wroteBased on observation staff interviews and a clinical record review, the facility staff failed to establish/provide collaborative care (Hospice) for 3 of 12 residents (Resident #7, 8, and 12), in the survey sample.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to ensure that twelve hours of in-service education/training within twelve months was completed by five of five sampled Certified Nurse Aides (CNA) #7, 6, 3, 8 and 9.

Inspectors wroteBased on observation and staff interview the facility staff failed to maintain a clean and sanitary food preparation area in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and interview, the facility staff failed to implement an effective pest control program affecting dining services and as a result the facility as a whole.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure a resident's right to a dignified existence and self-determination for 1 Resident (#21) in a survey sample of 35 Residents.

Inspectors wroteBased on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible during the initial entrance of the facility.

Inspectors wroteBased on observation, interview, and clinical record review, the facility staff failed to provide a clean, comfortable, home-like environment for 3 of the 14 Resident rooms in Hall 100.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility failed to review and revise the care plan for 2 Residents (Residents #2, and #21) in a survey sample of 35 Residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and review of facility documents, The facility staff failed to follow a physician's order to ensure two resident received physician ordered medications for two (2) of 35 residents (Resident #38, #21), in the survey sample.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 1 Resident in a survey sample of 35 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed for two residents (Residents #2, and #49) to ensure pharmacy recommendations were obtained and acted upon, in the survey sample of 35 Residents.

Inspectors wroteBased on the interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free from unnecessary psychotropic medications for 1 Resident (#49) in a survey sample of 35 Residents.

Inspectors wroteBased on inspection of medications on one medication cart and the facility's Stat box, facility staff failed to ensure medications for resident administraton were not expired.

Inspectors wroteBased on observations, staff interviews, facility documentation review and clinical record review the facility staff failed to ensure 3 residents (Resident #43, #17, #7) of 34 residents in the survey sample, received care to prevent pressure ulcers from developing prior to an advanced stage which constitutes harm; facility staff failed to do initial and weekly assessments for 1 of 34 residents in the survey sample, Resident #19 and facility staff failed to provide pressure ulcer care as ordered by the physician for 1 of 34 residents in the survey sample, Resident #346.

Inspectors wroteBased on medical record review, staff interviews and facility document review the facility failed to ensure that 5 of 34 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #5, #9, #19, #346, and #15.

Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 3 of 34 residents (Resident #348, Resident #5 and Resident #9) in the survey sample.

Inspectors wroteBased on general observations, clinical record review, staff and resident interviews, the facility staff failed to ensure resident rooms were maintained clean comfortable and homelike for 3 resident rooms on the quarantine unit, room [ROOM NUMBER] (A&B), #204 (B) and #207 (A).

Inspectors wroteBased on a complaint investigation, observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to ensure 4 of 34 residents (#152, #151, #30, #43) were free of the misappropriation of their narcotic medications, and ensure their standards and practices prevented reoccurrence.

Inspectors wroteBased on resident and staff interviews, clinical record review and facility document review, the facility staff failed to ensure the baseline care plan summary was completed for 3 out of 34 residents (Resident #346, Resident #347 and Resident #147) in the survey sample.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 2 of 34 residents (Resident #346 and Resident #22) in the survey sample.

Inspectors wroteBased on staff interviews and facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on observations, clinical record review, staff and resident interviews and facility documentation, the facility staff failed to assure the 5 agencies were sufficiently oriented to the facility's operational systems necessary to provide care and services.

Inspectors wroteBased on observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to ensure the system and disposition of all controlled drugs was in place and implemented to enable accurate reconciliation for 1 out of 34 residents (#146), as well as during the facility's physical inventory of their stored controlled medications at each shift change AND The facility staff failed to provide routine pharmacy services for Resident #20.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure 2 of 34 residents (Resident #347 and Resident #147) in the survey sample were free of significant medication errors.

Inspectors wrote2. The facility staff failed to offer and provide Resident #147 with an alternative or substitute for his lunchmeal. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis. The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. [...]

Inspectors wroteBased record review and staff interview the facility staff failed to ensure the Quality assurance and performance (QAPI) program include monitoring, and measuring performance activities.

Inspectors wroteBased record review and staff interview the facility staff failed to implement corrective action and monitor to ensure the Quality assurance and performance (QAPI) program to ensure performance goals or targets are achieved. activities.

Inspectors wroteBased on observations, staff interviews, clinical record review, and review of facility documents, the facilitys staff failed to ensure infection control measures and practices were in place in the laundry room and 3 resident rooms on the quarantine unit (Room's 202, 204 and 207), in the survey sample. 1. The facility failed to ensure that all laundry was handled, stored, and processed in a safe and sanitary method. During the initial of the laundry on 5/4/21 at approximately 1:15 p.m., the following observations were made with the Housekeeping Supervisor present; Multiple Hoyer slings were observed on top of numerous pillows in the corner against the wall beside the washing machines. The Housekeeping supervisor stated they were slings which were no longer used therefore; they needed to be stored someplace and the pillows were there to be washed and returned to service. [...]

Inspectors wroteBased on medical record review, facility document review staff interviews and family interview the facility staff failed to ensure one resident's daughter was called for a zoom care plan meeting after an invitation was sent for 1 of 34 residents in the survey sample, Resident #5.

Inspectors wroteBased on a complaint investigation, a medical record view, staff interviews and family a interview the facility staff failed to follow-up with a resident's choice of an attending physician in March of 2020 to determine if the provider could meet the requirements for care for 1 of 34 residents in the survey sample, Resident #9.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure call bells were within resident reach for two of 34 residents in the survey sample, Resident #17 and #42.

Inspectors wroteBased on staff interview, and facility document review, it was determined that facility staff failed to ensure that the state inspection results were easily accessible to all residents.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to ensure privacy during wound care for 1 of 34 residents (Resident #7), in the survey sample.

Inspectors wroteBased on observations, clinical record review, staff and resident interviews, the facility staff neglected to provide the necessary care and services for 1 of 34 residents (R#147) in the survey sample and failed to ensure a resident was free from abuse resulting in needless pain for 1 of 34 residents (Resident #36), in the survey sample.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to send all the necessary documentation; including care plan goals with the resident upon transfer to the hospital for 2 of 34 residents in the survey sample, Resident #17 and #346.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for 1 of 34 resident's (Resident #346) after being transferred and admitted to the hospital.

Inspectors wroteThe facility staff failed to ensure a comprehensive care plan was developed within seven (7) days after completion of the comprehensive assessment for 1 of 34 residents in the survey sample, Resident 40. 1. For Resident #40, the facility staff failed to ensure resident had a comprehensive care plan developed within 7 days after completion of the comprehensive assessment. Resident #40 was admitted to the facility on [DATE]. Diagnosis included but were not limited to Vascular Dementia Without Behavioral Disturbance, Cerebrovascular Disease, Unspecified and Type 2 Diabetes Mellitus With Other Circulatory Complications. Resident #40's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/05/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. [...]

Inspectors wroteBased on resident interview, staff interviews, clinical record review, and review of facility's documents, the facility staff failed to ensure 1 of 34 residents in the survey sample (Resident #346's) abdominal surgical wound had an alternate treatment until the primary treatment (a negative pressure wound vac) was available. 2. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment was coded for having an abdominal surgical wound requiring surgical wound care (wound vac.) The admission Assessment under skin was coded for having an abdominal surgical wound - area measured 2.8 cm x 3.8 cm x 1.1 cm. [...]

Inspectors wroteBased on observations, clinical record review, staff and resident interviews, the facility staff failed to follow physician orders to provide foot care for 1 of 34 residents (R#147) in the survey sample.

Inspectors wroteBased on a resident interview and staff interviews the facility staff failed to ensure 1 of 34 residents in the survey sample received appropriate sized incontinent products for 3 days, Resident #5.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation, the facility staff failed to ensure 1 of 6 residents (Resident #346) in the survey sample had dialysis orders.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure the physician reviewed pharmacy recommendations for 2 residents (Resident #4, #43) of 34 residents in the survey sample.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure that PRN (As Needed) orders for psychotropic medication was not ordered for longer than 14 days without a documented rationale for continued use for 1 resident (Resident #43) of 34 residents in the survey sample AND failed to implement Gradual Dose Reduction (GDR) interventions for the use of psychotropic medication as used by Resident #15.

Inspectors wroteBased on a complaint investigation, observations, resident interview and facility documentation, the facility staff failed to provide a separately locked, permanently affixed compartment for all controlled drugs to include those brought from resident homes on admission for 1 of 34 residents (Resident #146) in the survey sample.

Inspectors wrote2. Resident #147 was not able to chew and consume the meat served to him during the lunchmeal on 5/4/21. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis. The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. [...]

Inspectors wroteBased on observation, staff interview, and review of facility documents, the facility's staff failed to ensure on 5/10/21, the dishwasher temperature reached the appropriate wash temperature to sanitize the after breakfast dishes.

Inspectors wroteBased on staff interview and a review of facility documents, the facility's staff failed to conduct an ongoing review for antibiotic stewardship for one person in a survey sample of 43 residents.

Inspectors wroteBased on observation, staff interview, and a review of facility documents, the facility staff failed to designate at least one qualified Infection Preventionist.

Inspectors wroteBased on observations, staff interviews and facility documentation. The facility staff failed to implement COVID-19 testing to all staff.

Inspectors wroteBased on observation, clinical record review, staff interview, the facility staff failed to ensure 1 of 35 Residents (#39) in the survey sample was seen by a physician or his/her designee at least every 60 days.

Inspectors wroteBased on observations, staff interviews and facility documentation the facility staff failed to ensure that opened food products were properly dated, labeled, and stored in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, staff interviews and facility document review the facility staff failed to perform hand hygiene practices to provide a safe, sanitary environment and to help prevent the development and transmission of disease and infections; and failed for one of 35 residents, Resident #154's, Foley catheter tubing and bag in a manner in accordance with infection control standards and practices to help prevent associated urinary tract infections.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed for 1 of 35 residents in the survey sample, to ensure that the assessment accurately reflected Resident #22's status.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to implement an approach listed in the residents Comprehensive Person-Centered Plan of Care for 2 of 35 residents in the survey sample (Resident # 154 & #10). The facility failed to implement an indwelling catheter securement device for Resident #154 and failed to administer medications for seizure disorder and Parkinson's Disease for Resident #10.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise two of 35 residents (Resident #30 and #39) comprehensive person-centered care plans in the survey sample.

Inspectors wroteBased on record review and staff interview, the facility staff failed to provide one resident (Resident #10) in the survey sample of 35 residents, with physician ordered medications.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 35 residents in the survey sample received appropriate care and services to prevent complications from an indwelling Foley catheter, Resident # 154.

Inspectors wroteBased on observations, clinical record review and staff interview the facility staff failed to ensure 1 of 35 residents in the survey sample respiratory care equipment was maintained in a manner to ensure optimal functioning, Resident #49. The fixtures on both sides of the oxygen concentrator cabinet that hold the external air filters in place were missing.

Inspectors wroteBased on record review and staff interview the facility staff failed to provide pharmacy services to one resident (Resident #10) in the survey sample of 35 residents. Resident #10 was not provided physician ordered Keppra (a medication used for the treatment of seizure disorder) due to the medication not being available.

Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure a PRN (as needed) psychotropic medication (Xanax-anxiety medication) was limited to 14 days for 1 out of 35 residents (Resident #27) in the survey sample who was receiving a PRN (as needed) psychotropic medication.

Inspectors wroteBased on clinical record review, staff interview and facility documentation the facility staff failed to notify the physician and/or his designee of laboratory results for 1 of 35 resident (Resident #24) in the survey sample.