Baywood Crossing Rehabilitation & Healthcare Cente

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to be informed, in advance, of the care to be furnished for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to ensure that a consent was signed by Resident #1 for Mirtazapine (an antidepressant medication). The failure could place residents at risk of not having an opportunity to refuse medications, ask questions regarding medications and/or be knowledgeable regarding side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) of 10 residents reviewed for resident records.1. The facility failed to ensure that antidepressant monitoring documentation was accurate and/or complete for Resident #1. 2. The facility failed to ensure that wound care documentation was accurate and/or completed for Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5.3. The facility failed to ensure that Resident #1 was seen by a physician during her admission at the facility from 1/13/2026 through 2/18/2026. This failure could place residents at risk of an inaccurate medical record and could place the residents at risk of harm and health decline and/or possible missed diagnosis.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine and 24- hour emergency dental care for 1 of 11 residents (Resident #1) reviewed for dental services in that: The facility failed to assist Resident #1 with obtaining dental services between 7/6/25 when dental pain was noted in Resident #1's electronic medical record and on 8/12/25 when Resident #1's family member made a grievance with the facility regarding Resident #1 wanting to see a dentist. This failure could place residents at risk of not having their oral health care needs met or dental pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 2 (Resident #69 and Resident #302) of 7 residents reviewed for care plans. 1. The facility failed to ensure Resident #69's care plan included information regarding assist rails. 2. The facility failed to ensure Resident #302's care plan included information regarding her use of CPAP and advance directives information. The failure could place residents at risk of not receiving appropriate care and interventions to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails prior to installation and obtain informed consent prior to installation for 2 (Resident #69 and Resident #5) of 8 residents reviewed for use of side rails. The facility failed to ensure Residents #69 and #5 had documentation and orders prior to installation of bed rails. This failure could place residents at risk of injury, not have adequate education regarding bed rails and/or staff not have adequate communication regarding residents' use of bed rails.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #302) of 7 residents reviewed for advance directives. The facility failed to ensure that Resident #302's advance directives was clearly identified and documented in the resident's electronic medical record and was not care planned until [DATE] when the resident was admitted [DATE]. The failure could place residents at risk of not having their end of life wishes honored and having incomplete records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 medication fridges reviewed for storage of drugs. The facility failed to ensure that food items were not stored in the medication fridge per facility policy. This failure could place residents at risk of medications being cross contaminated with food items.

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Quetiapine fumarate (Seroquel) that was administered to Resident #3. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 4 of 20 (Resident # 8, #26, #76 and & #97) residents review for accuracy of assessment. Resident # 8, #26, #76 and resident #97 were not accurately assessed for their oral dental needs on their MDS assessments. Resident # 76 was not accurately assessed for his vision on his annual MDS assessment. These failures could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to create a comprehensive resident-centered care plan with measurable objectives for person-centered care for 3 of 21 residents reviewed for care plan development (Residents # 17, 52, 158). --- Resident # 17 did not have a care plan for ADL assistance --- Resident # 52 did not have a care plan for ADL assistance --- Resident # 158 did not have a care plan for ADL assistance These failures placed residents at risk of not receiving accurate care and services according to their individual needs.

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Quetiapine fumarate (Seroquel) that was administered to Resident #3. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent.

Inspectors wroteBased on interviews and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR ) Screening for 1 of 3 residents (Resident #8) reviewed for resident assessments. The facility failed to review Resident #8's PASRR level 1 assessment for accuracy and refer Resident #8 for further assessment for services. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental services to meet the needs of 1 of 21 residents reviewed for dental services. (Resident #76) The facility did not assist Resident #76, who had missing teeth and dental decay, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 6 residents (Resident #15), 1 of 1 medication storage rooms, and 1 of 3 medication carts, reviewed for pharmacy services in that: 1. The facility failed to order medications timely for Resident #15 which resulted in missed administration observed on 2/22/23. 2. The facility failed to ensure that expired medications were not stored with current medications in the medication storage room and the medication cart. This failure could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 days reviewed for RN hours, in that: Facility failed to make sure there was RN coverage for 4 days in the facility. This failure could place residents at risk of not receiving related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities, which involved 1 of 6 residents (Resident #15), and 1 of 5 staff (Med Tech A) reviewed for medication errors. Med Tech A failed to administer 2 medications (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) to Resident #15 on 02/22/2023. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions.