Baywind Village Skilled Nursing & Rehab

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, dispensing and administering of controlled medications and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 2 of 3 residents (Residents #1 and Resident # 2) reviewed for pharmacy services. Med Aide B signed out a controlled pain medication from the narcotic control book, did not sign off on the Electronic Medical Administration Record that a controlled medication was administered for Resident #1. LVN A signed out a controlled antianxiety medication from the narcotic control book, did not sign off on the Electronic Medical Administration Record that a controlled medication was administered for Resident #2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 1 of 3 residents (Residents #1) reviewed for pharmacy services. -LVN V and RN E, who signed out control pain medication from the control book, did not sign off on the TAR or MAR that control medications were administered for Resident #1. This failure could place residents at risk of not receiving their medication and drug diversion. Record review of Resident #1's face sheet dated 11/05/25 revealed an [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 2 of 4 (Resident #76 and Resident #293) residents reviewed for colostomies (surgical opening in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). The facility failed to ensure training, care and documentation was consistent for Resident #76 and Resident #293 as bowel movements were not consistently documented, a colostomy was documented as an ileostomy/urostomy and colostomies were not consistently emptied. The failure could place residents at risk of complications related to a colostomy and emotional distress. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1(Resident # 64) of 18 residents reviewed for care plan. Resident #64's care plan was not revised to reflect her D\C use of catheter on 04/20/25. This failure could place residents at risk of not receiving needed services and care to improve their health. Findings Include: Resident #64: Record review or Resident #64's face sheet, dated 05/05/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included essential hypertension (high blood pressure), type 2 diabetes mellitus without complications, lack of coordination, and muscle weakness. [...]

Inspectors wroteBased on interview, and record reviews the facility failed to ensure the residents had the right to be free from abuse for 1 of 6 residents (CR#1) reviewed for abuse. The facility failed to ensure CR#1 was free from abuse when CNA A physically abused CR #1 on 04/24/24 and threatened CR #1's roommate. The noncompliance was identified as PNC. The noncompliance began on 04/24/24 and ended on 04/24/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of being abused.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative when the resident experienced a significant change in condition for 1 (CR #1) of 5 residents reviewed for resident rights. The facility failed to notify CR #1's Responsible Party when she had a hypotensive event and refused to go to the hospital. This failure could result in the resident representative not being aware of conditions that may require them to make medical decisions.

Inspectors wroteBased on interview and record review, the facility failed to provide and document adequate preparation to residents to ensure safe and orderly transfer or discharge from the facility, for 1 (CR #2) of 3 residents reviewed for transfer/discharge. The facility failed to ensure CR #2 was discharged with Home Health Services in place. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 18 residents (CR #1) reviewed for resident rights. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from CR #1 prior to administering Zoloft, an antidepressant used to treat depression. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and respect for 1 of 9 (Resident #1) residents observed for dignity in that: -The facility failed to have a privacy curtain in Resident #1's room during wound dressing change. This failure could affect resident (s) that required assistance with care at risk for embarrassment and lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections for 1 of 9 (Resident #1) residents reviewed for infection control in that: -LVN A failed to practice infection control when changing Resident #1's dressing to the sacrum. This failure placed resident at risk for cross contamination and spread of infections and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #1 and #3) of 3 residents reviewed for infection control. -CNA-A did not wash or sanitize her hands in between assisting multiple residents with feeding. This failure could place residents who required feeding assistance with cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the facility provided pharmaceutical services (including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 5 residents (Resident #127) reviewed for pharmacy services. -The facility failed to ensure that Resident #127's Retacrit injection, a medication used to treat anemia caused by chronic kidney disease, was received from the pharmacy. -The facility failed to ensure that Resident #127's Retacrit injection, a medication use to treat anemia caused by chronic kidney disease, was administered per physician order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food service safety, in that: -1 plastic container of expired food was present in the refrigerator. This failure could place residents at risk for cross-contamination and foodborne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #127) reviewed for resident records, in that: -Resident #127's progress notes were not complete or accurate regarding her Retacrit medication. This deficient practice placed residents who receive medications from facility staff at risk for less than therapeutic benefits and/or not receiving ordered medications due to incomplete documentation.