Bayside Village

Inspectors wroteBased on interview and record review the facility failed to timely provide requested medical evaluation and treatment for two Residents (R1 & R4) out of four residents reviewed for a change in condition. This deficient practice resulted in delayed medical treatment, worsening of condition, and dissatisfaction with care.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify high fall risk residents, implement a fall prevention program and care plan interventions to prevent falls for three Residents (R1, R2 and R3) of three residents reviewed for falls. This deficient practice resulted in the potential for continued and/or increased falls with possible injury related to staffs' lack of knowledge of residents identified as high fall risk requiring increased supervision.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure supervision, including following care plan interventions to prevent a fall for 1 Resident (#1) of 3 residents reviewed for falls with injury. This deficient practice resulted in a fall with major injury (pelvis fracture) for R1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess elopement risk assessment, ensure exit doors were properly secured, and provide adequate supervision to prevent an elopement from the facility for one Resident (#1) of 1 resident reviewed for elopement risk. This deficient practice resulted in an Immediate Jeopardy when Resident #1 exited the facility unsupervised for approximately 30 minutes in 53 degree weather without proper attire and was found in a ditch where Resident #1 fell and was complaining of being cold and had head and neck pain, which required transfer to the Emergency Department (ED) for evaluation. after 30 minutes being outside in 53 degree weather without proper attire or footwear. This deficiency pertains to Intake 2635984.

Inspectors wroteThis deficient practice pertains to Facility Reported Incident (FRI) 61588. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent a fall, adequate supervision with use of a razor, and ensure reassessment and follow-up for exit-seeking for three Residents (R7, R23, & R38) of 12 residents reviewed for accidents/hazards/supervision. This deficient practice resulted in harm for R7 who incurred a fall with major injury (right pubis fracture), a tongue injury related to unsupervised access to hazardous hygiene supplies, and lack of accurate assessment data to ensure resident safety. This part of this citation is related to complaint intake #2605430

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Nurse (RN) was available for eight consecutive hours during a 24-hour period. This deficient practice had the potential for unmet care needs which could affect all 52 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for one of five Certified Nurse's Aides (CNA's) at least every 12 months. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 52 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure written communication of Monthly Medication Review (MMR) recommendations to the physician for five Residents (#2, #5, #6, #37, and #38) of five residents reviewed for MMRs. This deficient practice resulted in the absence of written MMR recommendations for the last year and had the potential to affect all 52 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure performance improvement projects/activities were conducted to ensure problem areas were identified, tracked, and improvement attained. This deficient practice resulted in lack of improvement in previously deficient

Inspectors wroteBased on interview and record review the facility failed to ensure quality assessment and assurance (QAA) committee meetings were held quarterly with the participation of all required members. This deficient practice resulted in the absence of a required QAA member (Medical Director) in the second quarter of 2025, which had the potential to affect all facility residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurses Aide (CNA) training of no less than 12 hours per year was completed for one CNA O of five CNA's reviewed for nurse aide training hours. This deficient practice resulted in the potential for unmet resident care needs for all 52 residents that reside in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment as evidenced by serving residents their meals on institutional trays and having a common area with a worn down and deteriorating conditions of furnishings and wall finishes at the nursing station.

Inspectors wroteBased on interview and record review, the facility failed to:- provide written information on the facility's bed hold policy for five Residents (#27, #15, #2, #3, and #7).- provide written transfer notifications to the resident, and resident's representative for four Residents (#15, #2. #3 and #7).of five residents reviewed for transfers out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one medication cart of three medication carts reviewed were attended and or locked and all resident medications were secured and or consumed for one Resident (#27) of fifteen residents reviewed for medication storage.

Inspectors wroteBased on interview and record review the facility failed to attempt a gradual dose reduction for one resident (Resident #37) out of five residents reviewed for psychotropic drug use.

Inspectors wroteBased on interview and record review the facility failed to ensure the PASARR (Preadmission Screening/Annual Resident Review) level I ([one] (DCH-3877) was obtained annually for one Resident (#6) of two residents reviewed for PASARR requirements .

Inspectors wroteBased on observation, interview, and record review the facility failed to update a comprehensive care plan for 1 Resident (#23) of 15 residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for supplemental oxygen and ensure respiratory equipment was changed, labeled, and appropriately stored for two Residents (#13 & #27) of two residents reviewed for respiratory care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician assessments and visit progress notes, including review of the program of care and resident condition, were available in the medical record of one Resident (#25) of 15 residents reviewed for physician visits. This deficient practice resulted in potential delinquent execution of care, unmet care needs, and lack of coordination of care.

Inspectors wroteBased on interview and record review the facility failed to ensure physician visits were completed timely for two Residents (#7 & #8) of 15 sampled residents reviewed for physician visits. This deficient practice resulted in extended time frames between physician visits and the potential for unaddressed medical needs.

Inspectors wroteBased on interview and record review, the facility failed to prevent administration of unnecessary medications for one Resident (#10) of five residents reviewed for unnecessary medication.

Inspectors wroteThis deficient practice pertains to Intake 2565663Based on interview and record review, the facility failed to ensure one Resident (R25) of one resident reviewed for significant medication errors received medications at the frequency ordered by the physician. This deficient practice resulted in inaccurate medication dosages and the potential for subtherapeutic drug levels, blood clot formation, and cerebrovascular accident (CVA - stroke).

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Proper care of a catheter, 2. Accurate and timely documentation was entered for care decisions, and 3. Notification of significant changes were communicated to the physician for one Resident #5 (R5) of three residents reviewed for quality of care. This deficient practice resulted in harm when R5 was hospitalized due to a ruptured bladder, urinary tract infection, and septic shock (a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.), with continued decline resulting in death.

Inspectors wroteThis deficiency pertains to intake #MI00152671. Based on interview and record review the facility failed to ensure adequate assistance and assistive devices were used to prevent a fall with major injury resulting in harm for one resident (R2), out of three residents reviewed for falls. This deficient practice resulted in hospitalization due to a pelvic fracture.

Inspectors wroteThis deficiency pertains to Complaint Intake #MI00150445. Based on interview and record review, the facility failed to prevent a significant medication error for one Resident (R1) of four residents reviewed for medication errors. This deficient practice resulted in the potential for adverse side effects and required transfer to an acute care hospital emergency department for monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate numbers of staff to meet the needs of four (Residents #47, #7, #15, and #24) of fifty-seven residents sampled for sufficient staffing and three [Resident #C1 (C1), Resident #C4 (C4), and Resident #C7 (C7)] of seven residents from a confidential resident council meeting. This deficient practice resulted in the potential for a decline in resident quality of life and/or quality of care, not receiving medications timely, and unmet care needs for all fifty-seven residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three Certified Nurse Aides (CNA) [P, S, and T] had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for Residents. This deficient practice has the potential for staff to lack the necessary training to adequately meet the needs of all 57 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews for three of three Certified Nurse Aides (CNA's) [P, S, and T] at least once every 12 months. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 57 residents living in the facility.

Inspectors wroteDuring the breakfast meal on 7/9/24 at 7:57 a.m., Staff U was observed removing a baseball-style cap from their head and scratching their scalp before placing the cap back on their head. Staff U began scratching their facial hair before touching the condiments, tableware, and food on a tray next to the serving station. Staff U did not perform hand hygiene after touching their scalp and facial hair and beginning to touch items used or consumed by residents. On 7/9/24 at 8:15 a.m., Staff U began assisting with preparing resident meal trays without performing hand hygiene. At 8:28 a.m., Staff U was observed to be touching the front of their shirt, running their hand from their chest down to their abdomen. Staff U did not perform hand hygiene after touching their shirt and commencing with meal tray set-up. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 57 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aide training of no less than 12 hours per year, for three Certified Nursing Assistants (CNA) P, S, and T of five CNA's reviewed for nurse aide training hours. This deficient practice resulted in the potential for unmet resident care needs for all 57 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure training on behavioral health care was provided for two of three staff reviewed for required behavioral health care training. This deficient practice had the potential to result in unmet behavioral health care needs for residents, with the potential to affect all 57 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to revise care plans after multiple falls for four Residents (#17, #26, #36, and #47) of fourteen residents reviewed for care planning. This deficient practice resulted in the potential for further falls and the potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits accurately reviewed the total program of care for four Residents (R24, R26, R36, & R38) of four residents reviewed for physician visits. This deficient practice resulted in the potential for lack of comprehensive and supervised medical care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inhalers and eye drops were labeled with dates when opened according to facility policy for two medication carts of two medication carts reviewed for medication storage and labeling. This deficient practice resulted in the potential for administration of expired medications to nine residents receiving inhalers and five resident receiving eye drops.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate assessments, physician orders, risk education, medical justification, and care plans for restraints were in place for one Resident (R36) of one resident reviewed for restraints.

Inspectors wroteBased on interview and record review, the facility failed to ensure collaboration and communication between the facility and hospice provider for one Resident (R56) of one resident reviewed for hospice services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate medically related social services to one Resident #15 (R15) of one resident reviewed for social services care. This deficient practice resulted in a lack of supportive visits, delayed referral to a behavioral care provider, and psychosocial decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the timely reorder and acquisition of pressure ulcer wound treatment medication for one Resident (R51) of one resident reviewed for pressure ulcer treatment medication availability. This deficient practice resulted in the lack of prescribed medication and the potential for worsening of pressure ulcers for R51.

Inspectors wroteThis deficient practice has two parts: A and B. Part A: Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for one Resident (R24) of five residents reviewed for medication regimen reviews. This deficient practice resulted in the potential for the administration of unnecessary medication or a medication dosage in excess of what was required to treat the resident symptoms.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive Water Management Plan (WMP) for the control of Legionella in the potable water supply system. This deficient practice has the potential to lead to the growth and proliferation of Legionella in the water supply system and respiratory infections from the Legionella group bacteria affecting all 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent an elopement for one Resident (R1) out of three residents reviewed for elopement. This deficient practice resulted in an unsupervised exit from the facility and unsafe ambulation and wandering off facility property for a cognitively impaired Resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring and documentation of psychotropic medications for 4 residents (Resident #56, #36 #50 and #51) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for serious side effects and adverse reactions, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of abnormal vital sign results for 2 residents (Resident #1 and #56) reviewed for notification of changes, resulting in the lack of assessment and monitoring, and the potential for the worsening of a medical condition and delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance for two residents (Resident #48 and Resident #18) who depend on staff assistance to complete activities of daily living, resulting in the potential for skin break down and feeling forgotten for Resident #48 and the potential for dental caries for Resident #18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an in-use oxygen tank was full and functional for 1 resident (Resident #1) reviewed for oxygen/respiratory care, resulting in the potential for respiratory distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure systems were implemented to accurately account for controlled substances when licensed nurses were not signing out controlled substances from narcotic sheets prior to administration of the controlled substances, resulting in the potential for drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #45) was free from significant medication errors when a medication was not administered according to the physician orders.