Bywood East Health Care

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate infection control while providing laundry services as well as failed to review the facility Infection Prevention Program policy annually. These deficient practices had the ability to affect all residents who resided in the facility.

Inspectors wroteBased on interview and document review the facility failed to have the appropriate funds available for 2 of 3 (R41, R21) Medicare/Medicaid residents who wanted to withdraw funds outside of scheduled withdrawal hours set up by the facility. In addition, insignificant funds were available on the evening shift for any residents. This had the potential to affect all residents who kept funds with the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to provide a safe, sanitary and comfortable environment for 7 of 7 residents (R24, R33, R62, R9, R56, R12, R20) reviewed for environment.

Inspectors wroteBased on interview and document review the facility failed to ensure bait stations were monitored and serviced to prevent/reduce pest problems for 6 of 6 residents (R24, R33, R62, R9, R56, R12) reviewed for environment. This had the potential to affect all 64 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure a pre-admission screening and resident review (PASARR) level two screening referral was acted upon for 1 of 1 resident (R2) reviewed for PASARR screening process.

Inspectors wroteBased on observation and interview, the facility failed to ensure survey results were available without an individual needing to ask to see the results. This deficient practice had the potential to impact on any person wishing to see, but not ask for, the survey results.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff posting included the current census and visible hours worked. This had the potential to impact all residents who resided at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure shared resident' rooms had adequate floor space (i.e., at least 80 square feet [SF] per resident) for 23 of 23 rooms (101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, 317 ). This had potential to affect any resident who currently or potentially could occupy these shared room spaces.

Inspectors wroteBased on observation, interview and document review, the facility failed to protect residents from physical abuse by contracted staff for 1 of 3 residents (R1) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to implement written policies to prohibit and prevent abuse from contracted staff and failed to include protocols for providing abuse prohibition education or verification of abuse education for contracted staff. This had the potential to affect all current and future residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and develop or implement interventions to reduce the risk of ongoing potential physical and/or mental abuse for 1 of 3 residents (R1) reviewed for resident-to-resident abuse allegations. R1 was repeatedly harassed and physically grabbed by another resident (R2) which contributed to ongoing emotional distress and hospitalization resulting in psychosocial harm.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident-to-resident physical altercation which contributed to feelings of fear and mental anguish was reported to the State agency (SA) immediately, but not later than two hours after the allegation is made of abuse for 1 of 3 residents (R1) reviewed reporting. R1 was grabbed and had her hair pulled by R2 which caused R1 psychosocial harm.

Inspectors wroteBased on interview and document review the facility failed to provide a resident's prescribed therapeutic diet when on 11/17/25, a registered nurse (RN)-A assisted R3 to purchase a sticky bun from the vending machine at the facility because he was unable to do so himself for 1 of 3 residents (R3) reviewed for food and drink. While eating the sticky bun R3 started to choke and went unresponsive, cardiopulmonary resuscitation (CPR) was started and R3 was transferred to the hospital where he subsequently died on [DATE]. The immediate jeopardy began on 11/17/25 when RN-A purchased a non-pureed item out of a vending machine for R3, R3 choked on the item resulting in his death was identified on 11/17/25. The chief financial officer (CFO)-A, a director of nursing (DON) was notified of the immediate jeopardy at 3:19 p.m. on 12/15/25. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide trauma informed care including failure to complete a comprehensive assessment that identified triggers in order to eliminate or mitigate the risk of re-traumatization for 1 of 1 resident (R2) who had a known history of trauma prior to admission. The facility's failures resulted in actual psychosocial harm for R2 when R2 was involved in two resident to resident abuse incidents that caused R2 ongoing fear and aggressive reactions that were uncharacteristic of R2.

Inspectors wroteBased on observation, interview, and document review the facility failed to prevent and protect 3 of 3 residents (R1, R2, and R3) from physical and verbal abuse when staff failed to remove R2 and bystanders after R1 demonstrated aggression toward R2 which led to physical altercation between R1, R2, and R3. In addition, facility failed to comprehensively assess for triggering behavior patterns and implement interventions that could decrease the risk and/or prevent for recurrent incidences of resident-to-resident abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure the comprehensive Minimum Data Set (MDS) was completed in a thorough and timely manner to reflect actual resident' status and ensure appropriate care-planning for 1 of 3 residents (R2) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents were protected from resident-to-resident abuse for 2 of 2 residents (R3 and R4) who were in a verbal and physical altercation which resulted a thoracic (T9) fracture with facial injuries for R4 and a swollen, bruised hand for R3. This resulted in an Immediate Jeopardy (IJ) for both R3 and R4. The IJ began on 8/14/25 at 10:45 p.m., when R3 and R4 had a verbal altercation, were separated by staff with one verbal redirection towards R3, but no other behavioral interventions were implemented despite a significant history of physical altercations for both residents, leading to R3 seeking R4 out again, re-engaging in the verbal altercation before starting a physical altercation which resulted in R4 needing emergency medical treatment for facial lacerations and a T9 fracture. [...]

Inspectors wroteBased on observation, intervention and document review the facility failed to ensure a safe environment and prevent fire hazards for 2 of 2 residents (R5 and R6) when residents were found to be smoking in resident rooms with staff awareness. This resulted in an immediate jeopardy (IJ) for R5 and R6 and could lead to serious harm for all residents, staff, and visitors at the facility. The IJ began on [DATE] at. 4:54 p.m., when a strong smell of cigarette smoke was noted on the third floor near the elevator and trained medication aide (TMA)-A and TMA-B stated the odor was coming from room [ROOM NUMBER] (R6's room). R5 was observed in room [ROOM NUMBER] and was asked to leave by staff. During interview, R5 stated he was in the room and had just been smoking. The nightstand next to bed two was observed to be covered in cigarette ashes and there were multiple cigarettes burns on the floor. [...]

Inspectors wroteBased on interview and document review, the facility failed to immediately report an allegation of sexual abuse to the state agency (SA) for 1 of 1 resident (R1, R2) when R2 was found engaged in a sexual act with R1 without staff's knowledge of R2's consent.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate a resident-to-resident abuse allegation for 2 of 2 residents (R3 and R4) and a resident-to-resident sexual assault allegation for 2 of 2 residents (R1, R2) to determine incident details, interview all parties involved, appropriately assess and identify interventions to reduce likelihood of future abuse.

Inspectors wroteBased on observation, document review and interview, the facility failed to comprehensively develop and implement a resident centered care plan for 1 of 1 resident (R2) who was at risk of abuse and interventions were not identified to address the root cause of that risk and decrease the likelihood of abuse re-occurring.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure laundry was handled and transported in a way to prevent the spread of infection to the extent possible. This had the possible to affect all 70 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was reheated to an appropriate temperature to reduce the risk of foodborne illness for 12 residents who ingested the food item.

Inspectors wroteBased on interview and document review, the facility failed to ensure voiced allegations of potential verbal and/or mental abuse were reported to the administrator and State agency (SA) in a timely manner for 3 of 4 residents (R21, R26, R55) reviewed who reported potential allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure voiced allegations of potential verbal and/or mental abuse were acted upon, investigated, and if needed, adequate protection provided to ensure safety and well-being for 3 of 4 residents (R21, R26, R55) reviewed who reported potential allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with consumed medications to promote continuity of care and ensure accurate care-planning for 2 of 5 residents (R25, R4) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure resident care plans were comprehensive and up to date to ensure continuity of care for 3 of 3 residents (R55, R57 and R65) reviewed for comprehensive care plans.

Inspectors wroteBased on interview and document review, the facility failed to provide ongoing, comprehensive discharge planning to a lower level of care for 1 of 1 residents (R52) who wished to be discharged from the nursing home.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to promote acceptance with bathing and/or personal hygiene cares for 1 of 2 residents (R24) reviewed who appeared disheveled and had a pattern of refusing cares.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure repeated complaints of pleuritic and/or gastrointestinal distress (i.e., heartburn) were assessed and acted upon to determine what, if any, proactive interventions were needed to promote comfort and prevent complication for 1 of 1 resident (R5) reviewed who complained of heart pain.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure voiced complaints of difficulty hearing were acted upon, assessed, and if needed, treatment started or referred to audiology to promote quality of life for 1 of 1 resident (R24) reviewed who was hard of hearing (HOH).

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident who had multiple incidents of smoking indoors was reassessed for safe smoking for 1 of 2 residents (R32) reviewed for smoking.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a physician visit was completed in a timely manner (i.e., every 60 to 70 days) to promote continuity of care and reduce the risk of disease complication for 1 of 5 residents (R5) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff implemented appropriate and manufacturer-directed steps to prevent post-administration complication (i.e., thrush) of a steroid-infused inhaler for 1 of 1 residents (R4) observed to receive inhaled medication during the recertification survey.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations for standard-of-care laboratory monitoring with a consumed cardiac glycoside medication were acted upon and addressed in a timely manner for 1 of 5 residents (R5) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure consumed cardiac glycoside medication was appropriately monitored in accordance with the standard-of-care laboratory testing to help reduce the risk of medication toxicity for 1 of 5 residents (R5) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 1 of 5 residents (R22) over [AGE] years old whose vaccinations histories were reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the facility's state survey results were kept in a location that was readily accessible to all residents. This had the potential to affect all 70 residents and/or visitors who could wish to review the information.

Inspectors wroteBased on interview and document review, the facility failed to ensure a subset (i.e., discharge) Minimum Data Set (MDS) was completed and transmitted to the Centers for Medicare and Medicaid (CMS) database in a timely manner for 3 of 5 residents (R58, R62, R30) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure shared resident' rooms had adequate floor space (i.e., 80 square feet [SF] per resident) for 23 of 23 rooms (101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, 317 ). This had potential to affect 69 of 69 residents who currently or potentially could occupy these shared room spaces.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and appropriately transfer a resident off the floor after an unwitnessed fall with potential head injury for 1 of 1 resident (R2) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 1 residents (R1) who was assessed to be unsafe in the community and at risk of elopement. This failure resulted in an immediate jeopardy (IJ) when on R1 left the facility without supervision for appointments, got lost, and was gone for over 5 hours before staff were aware. R1 was found 7 hours later by family member (FM)-A. The IJ began on 9/18/24, at 1:15 p.m. when R1 was sent to his 2:00 p.m. appointment without an escort and subsequently missed a 3:00 p.m. appointment when he became lost. R1 was later found by his family member (FM)-A outside of a highly trafficked area hospital at 10:00 p.m. director of nursing (DON) and administrator were notified of the IJ on 10/10/24, at 12:52 p.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) adequately addressed and monitored a known rodent (mouse) infestation that had the ability to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a mouse infestation in the facility. This had potential to affect all 68 residents whom resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification to a provider/guardian for a missing resident for 1 of 1 residents (R1), who was sent to appointment without an escort and was missing for seven hours at the hospital until family member (FM)-A found him lost and confused looking for his room.

Inspectors wroteBased on interview and document review the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft and ensure a lock box was provided for personal property and/or monies for 1 of 1 resident (R1) who had loss of property after removing $50.00 from his account. R1had recent traumatic brain injury and no recollection where the money went. The facility also failed to investigate where the missing money went or implement safety measures to protect resident property from potential loss or theft.

Inspectors wroteBased on interview and document review the facility failed to timely report an allegation of missing resident for 1 of 1 resident (R1) who had a traumatic brain injury was cognitively impaired went missing from the facility and was later found on the local hospital grounds.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess to determine cause of falls and implement interventions to prevent further falls for 3 of 3 residents (R1, R5, R6) reviewed for falls. This resulted in an immediate jeopardy (IJ) for R1 when he had a fall that resulted in a diagnoses of traumatic brain injury with loss of consciousness and subarachnoid hemorrhage, brain bleed (bleeding in the space between the brain and the tissue covering the brain). R1 remained hospitalized . The IJ began on 8/13/24 at 1:30 a.m., when R1 had a second unwitnessed fall and hit his head. R1 was sent to the hospital and was diagnosed with a subarachnoid hemorrhage. R1 had another unwitnessed fall on 8/18/24 at 12:45 p.m., and returned to the hospital. The administrator and director of nursing were notified of the IJ on 9/5/24 at 4:34 p.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification to a provider for change in condition related to falls, or treatment after falls for 3 of 3 residents (R1, R5, R6) reviewed for change in condition.

Inspectors wroteBased on interview and document review, the facility failed to develop a policy and procedure for physician delegation of tasks for disciplines working under the physician's supervision. This had the potential to affect all 69 residents residing at the facility.

Inspectors wroteBased on interview and document review, the facility failed to develop a policy and procedure for physician delegation of tasks to the dietician. This had the potential to affect all 69 residents residing at the facility.

Inspectors wroteBased on interview and document review, the failed to establish and implement a policy related to the responsibility of the administrator to report to and being held accountable by the Governing Body. This had the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to develop a policy and procedure defining the responsibilities of the Medical Director.

Inspectors wroteBased on interview and document review, the facility failed to ensure the State Agency (SA) was notified as required when the current director of nursing (DON) was hired for the position. This deficient practice had the potential to affect all 69 residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure newly admitted residents received a physician visit every 30 days for the first ninety days for 1 of 3 residents (R5) reviewed for 30-day physician visits. In addition, the facility failed to ensure long term residents received routine physician visits (every 60 days) for 3 of 3 residents (R1, R5, R6) reviewed for routine physician care.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of verbal abuse were reported immediately (within two hours) to the State Agency (SA) for 2 of 3 residents (R1, R3) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure 54 of 72 residents with personal funds accounts (including R1, R2, R4, R5, R6, R8) with the facility had access (and/or awareness of access) to their funds as soon as possible to meet their individualized needs, after hours, and on weekends.

Inspectors wroteBased on interview and document review, the facility failed to provide quarterly statements for resident personal fund accounts for 54 of 72 residents (including R2, R3, R4, R5, R6, R7, and R9) residents reviewed for personal fund accounts. R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. On 4/11/24 at 8:28 a.m., stated she does not remember getting a statement of her resident fund account but she would like that. R3's annual Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. On 4/11/24 at 8:41 a.m., R3 stated he had not gotten any statements from the facility and did not know how much money he has in the facility. R4's annual MDS dated [DATE], indicated R4 was cognitively intact. On 4/11/24 at 9:35 a.m., R4 indicated she had never gotten a statement for her funds in the facility that she could remember. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) adequately addressed and monitored a known rodent (mouse) infestation that had the ability to affect all 72 residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure an infection prevention and control surveillance system was created and implemented to identify, track, and analyze all resident infections to prevent the spread of communicable diseases and infectious organisms. In addition, the facility failed to have the infection control program reviewed annually. This had the potential to affect all 72 residents, staff and visitors in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a mouse infestation in the facility. This had potential to affect all 72 residents whom resided in the facility.

Inspectors wroteBased on interview, and document review, the facility failed to provide the opportunity for 4 of 4 residents (R17, R28, R42, R48) reviewed to participate in care planning and care conferences.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident records that contained private, medical, and personal information were not accessible to unauthorized personnel.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for one of two residents (R52) reviewed for PASARR.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 resident (R228) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal cares, including bathing and nail care, were offered or provided to maintain a dignified appearance and reduce the risk of complication (i.e., infection, skin impairments) for 1 of 1 resident (R20) reviewed who was legally blind.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess and implement new fall interventions for a resident with multiple falls to attempt to limit falls for 1 of 1 resident (R66) reviewed for falls. Additionally, the facility failed to accurately assess a resident observed with multiple burn holes in their clothing for safe smoking practices for 1 of 4 residents (R4) reviewed for smoking.

Inspectors wroteBased on interview and document review the facility failed to provide therapeutic diets as prescribed by the physician for 1 of 1 (R48) residents reviewed for diet restrictions.

Inspectors wroteBased on interview and document review, the facility failed to ensure binding arbitration agreements for 2 of 2 residents (R57, R67) were clearly explained in a form and manner that they understood prior to entering into the binding arbitration agreements.

Inspectors wroteBased on interview and document review, the facility failed to offer a neutral and fair arbitration process by ensuring both the resident and his or her representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties for 2 of 2 residents (R57, R67) reviewed for binding arbitration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure shared resident' rooms had adequate floor space (i.e., 80 square feet [SF] per resident) for 9 of 9 rooms (101, 102, 108, 109, 301, 302, 307, 308, 309) reviewed. This had potential to affect 27 of 27 residents who currently or potentially could occupy these shared room spaces.

Inspectors wroteBased on interview and document review, the facility failed to accurately assess 6 of 8 residents (R1, R2, R3, R4, R6, and R7) reviewed when their cognition and depression was not assessed on the minimum data set (MDS).

Inspectors wroteBased on interview and document review, the facility failed to develop and implement behavioral health comprehensive person-centered care plans providing care and services for 6 of 8 residents (R1, R2, R3, R4, R6, and R7) reviewed when their cognition and depression was not assessed, and recommendations from resident's psychologist were not added to the resident's care plans.

Inspectors wroteBased on interview, and document review, the facility failed to track behavior charting for resident to resident altercations for 4 of 8 residents (R1, R2, R3, and R4) reviewed when incidents occurred but not documented on the nursing assistant (NA) target behavior charting required to determine the residents' overall response to care plan interventions and meeting their behavior goals.