Baywood Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of bed or side rails (adjustable rigid bars attached to the side of a bed) for 10 of 36 residents (9. 21. 24, 29, 30, 34, 41, 42, 145, and 146) when: 1. Alternatives were not attempted prior to the use of bed or side rails for Residents 9, 34, 41, 42, 145, and 146; and 2. Bed or Side Rail Assessment was not done quarterly for Residents 21, 24, 29, and 30. These failures had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five residents (20, 29, and 145) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 29's physician's order for as needed psychotropic medication was not limited to 14 days of use; 2. Resident 20 received psychotropic medications without quarterly review on the use of these medications; and 3. Resident 145 received Abilify (an antipsychotic that helps treat several kinds of mental health conditions) with no specific behaviors (the way in which one acts or conducts oneself), identified and no evidence of monitoring for behaviors documented. [...]

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 25.93% when 7 medication errors occurred out of 27 opportunities during medication administrations for four out of six residents (5, 6, 14, and 146). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when expired medications and the medication opened over the period found in Medication Cart 1. This failure had the potential for residents to be given expired or over open period medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A Urinary catheter (a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drain bag and tubing was on the floor; 2. The staff provided ice to residents using ice from trays made in the employee room freezer; 3. Certified nursing assistant F (CNA F) brought the lunch tray to Resident 146 without sanitizing his hands; 4. Certified nursing assistant B (CNA B) walked out of Resident 17's room without removing his gloves and sanitizing his hands; 5. Licensed vocational nurse D (LVN D) administered eye drops to Resident 6 without changing his gloves and cleansing his hands; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat the resident with respect for one of 12 residents (34) when Resident 34 requested to have female certified nursing assistant (CNA) to work with her, but male CNAs were still assigned to her. This failure violated the resident's rights and had the potential to cause frustration for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (20 and 38) had informed consents (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). These failures resulted in the residents receiving psychotropic medications without being informed about their risks and side effects.

Inspectors wroteBased on interview and record review, the facility failed to timely complete and submit a Discharge Minimum Data Set (MDS, a clinical assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for two of four residents (25 and 31). This failure resulted in non-compliance with CMS regulatory requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure service provided to met professional standards when the licensed nurses did not follow the physician order to float Resident 27's heels while he was in bed. This failure had the potential for Resident 27 to develop skin damage to his heels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted clearly visible in a prominent place that was readily accessible to residents and visitors. This failure had the potential to result in nurse staffing information not available for resident's, families, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's recommendations were acted upon for two of 12 residents (14 and 20) when: 1. Resident 14's chewable Aspirin (a drug that reduces pain, fever, inflammation, and blood clotting) was not changed to plain film coated form of baby aspirin; and 2. Resident 20's consultant pharmacist's Note to the Attending Physician/Prescriber regarding duplicate therapy of Protonix (used to treat heartburn and certain other conditions caused by too much acid in the stomach) and Pepcid (used to treat heartburn and certain other conditions caused by too much acid in the stomach) was not presented to the physician. This failure had the potential for Residents 14 and 20 to receive ineffective and unnecessary medications that could negatively impact their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed employ sufficient staff with the appropriate competencies and skills sets to carry out the food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards for food service managers as a full-time, qualified dietetic supervisor when the dietitian was not full time. This failure had the potential to unsafe food practices and food-borne illness for 38 residents eating facility-prepared foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen freezer and the meal cart in a good and safe operating condition, when 1. Excessive ice buildup was observed in the reach-in freezer. 2. Kitchen Meal Cart 3 was missing a proper handle, and the meal cart door was no closing. These deficiencies could compromise the freezer's ability to keep food adequately frozen and the meal cart door may not prevent proper food temperature maintenance that could cause food-borne illness for 38 out of 39 residents who received meals prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of resident rooms have at least 80 square feet per resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the reach-in freezer in good and safe operating condition when the reach-in freezer had ice-build up and freezer temperature was negative forty degrees Fahrenheit. This failure had the potential to cause the freezer to be ineffective for keeping food frozen and may lead to food spoilage and food-borne illness (illness resulting from contaminated food) for 23 residents who received food from the kitchen out of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and comfortable temperature of 71 to 81 degrees Fahrenheit (F) when: 1. One of 12 sampled residents (Resident 9) complained that the room was cold; and 2. 12 resident rooms, dining/activity room, living room, and one of the two hallways were found to be below the comfortable temperature range. This failure had the potential to result in residents' decreased sense of well-being and exposed to an uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the manufacturer's recommendations for maintaining the bed side rails for 15 residents (3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 17, 18, 22, 23, and 24). This failure had the potential to place the residents at risk of entrapment and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the emergency kits (E-kits, containers with specialty medications which may be needed in an emergency) did not contain expired medications, when two of four E-kits had expired medications. This failure had the potential of a resident being administered an emergency medication which was expired, and not effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. The medication cart was locked when unattended; and 2. The opened multi-dose containers of house medications/supplements had no open date. These failures had the potential of medication (or other items) being taken without the nurse's knowledge and medications being held past the usage period after being opened.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Food preparation equipment were not maintained clean and/or in good condition including: a. Commercial can opener b. Cutting boards; 2. Five dented can goods were stored on the rack with ready to use cans; 3. Nine bananas with multiple blackish dots on top of the tray cart inside the dry storage area has no date; 4. One orange fruit soft and rotten with grayish particles, three pieces of green peppers has multiple blackish spots with grayish particles without date and one white onion inside the plastic has no date; and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for 5 of 12 residents (6, 8, 10, 18, and 24) when: 1. For Resident 6, oxygen tubing was not changed for 3 weeks; storage bag for oxygen tubing was not changed for about one and a half year; the humidifier bottle was undated; and the filter of oxygen concentrator was so dusty; 2. Certified nursing assistant F (CNA F) did not sanitize her hands before serving lunch tray to Resident 10; and 3. CNA G, CNA H, and CNA I did not sanitize their hands after carrying the chair and before feeding Resident 24, Resident 8, and Resident 18. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure need was accommodated and to ensure dignity was maintained for two of twelve sampled residents (10 and 24) when: 1. Facility staff failed to ensure a communication device was provided for Resident 10; and 2. Certified Nursing Assistant G (CNA G) were standing while feeding Resident 24. These failures had the potential to negatively affect the resident's physical and psychosocial well- being.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of whether the advance directive was discussed with one of 12 residents (Resident 13) was discussed with the resident or family upon admission/re-admission, when the Physicians Order for Life-Sustaining Treatment (POLST) section D was not filled in completely. This failure had the potential of the incorrect treatment being administered in a life-threatening emergency.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy for one of 12 residents (7) when activities assistant J (AA J) reported that she heard certified nursing assistant K (CNA K) slapped Resident 7 twice, but the incident was not reported to the state agency department.

Inspectors wroteBased on interview and record review, the facility failed to develop and accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority), received mental illness diagnoses and did not receive a level two screening to ensure they received the services needed for two of twelve sampled residents (5 and 6). This failure had the potential to put the residents at risk for not receiving appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two of 12 sampled residents (Residents 5 and 10) when: 1. Resident 5's antipsychotic medication (medications work by altering brain chemistry to help reduce psychotic symptoms like having false, fixed beliefs, hearing voices or seeing things that aren't there, and disordered thinking) care plan was incomplete and not person-centered; and 2. For Resident 10, there was no care plan developed specifically for communication deficit related to language barrier. These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of 12 residents (6) when Resident 6's electrocardiogram (EKG, records the electrical signal from the heart to check for different heart conditions) was not done every year as ordered by the physician. This failure had the potential to affect the resident's care and could jeopardize her health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their oxygen administration policy for one of two sampled residents (Resident 8) when staff did not place an Oxygen in Use sign outside the entrance to the resident's room. This failure had the potential to compromise the resident's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of resident rooms have at least 80 square feet per resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. The kitchen microwave was not clean; 2. Employee's food was inside the kitchen refrigerator; and 3. The test strip to check the red bucket (sanitizer bucket) was expired. These failures had the potential to cause food borne illnesses to the residents in the facility. 1. During the initial kitchen observation on 4/5/2022, at 8:28 a.m., there were brown, black, and white substances at the top of the inside of the microwave and food buildup. During a follow up observation and concurrent interview with the dietary aide (DA) on 4/5/2022, at 1:40 p.m., DA confirmed the above observation. DA stated the microwave was used to warm residents' food. DA tried to clean them but DA could not remove the debris. DA further stated it should have been replaced. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one opened multi-dose eye medication was dated with an open and discard date, to make sure it was not used beyond the discard date. The deficient practice had the potential for unsafe and ineffective use of medication being used past the expiration date.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022. The deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective infection process when: 1. Foley catheter (FC, a tube inserted in the bladder to drain urine) and drainage bag were in direct contact with Resident's wheelchair wheel. 2. Staff did not perform hand hygiene in between tasks. 3. One licensed nurse did not perform hand hygiene between tasks during tube feeding. These failures had the potential to result in transmission of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the following resident rooms provided less than 80 square feet per resident.