Lilac at Bayview, the

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with newly evident or possible serious mental disorders, intellectual disability, or related conditions were reviewed for level II pre-admission screening and resident review (PASRR) for one (Resident #87) of two residents reviewed for PASRR.

Inspectors wroteBased on observation, interview and record review, the facility failed to stop enteral feeding as ordered by the physician for one (Resident #305) of two residents reviewed for gastrostomy tube enteral feedings.

Inspectors wroteBased on interview and record review, the facility failed to ensure nutritional interventions were implemented as ordered by the physician for two (Residents #94 and #89) of nine residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not 5% or greater for two (Residents #254 and #305) of seven residents observed during medication administration, resulting in a medication error rate of 6.45%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were properly stored in accordance with professional standards of practice. Unsecured medications were found on two of four hallways and affected three residents (Residents #55, #52, and #73).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure the staff followed Enhanced Barrier Precautions (EBP) for two (Residents #254 and #305) of seven residents reviewed for infection with use of antibiotics.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement the comprehensive care plan to ensure the resident's medical, physical and psychosocial needs were met and failed to ensure a cognitively impaired resident's right to be free from abuse, including sexual abuse, was implemented for one (Resident #2) of 4 residents reviewed for resident-to-resident abuse, from a total sample of 7 residents.

Inspectors wroteBased on record review, facility investigation report review, interviews, and facility's Quality Assurance and Performance Improvement (QAPI) policy review, the facility failed to implement it's written policies and procedures outlined in the Quality Assurance and Performance Improvement (QAPI) plan and failed to use data contributing to the Root Cause Analysis (RCA) of an adverse event to develop relevant activities to prevent similar future events. This had the potential to affect not only 1 (Resident #2) of 4 residents reviewed for resident-to-resident abuse but all cognitively impaired resident residing in or admitted to the facility.

Inspectors wroteBased on a record review, interviews, and facility policy and procedure review, the facility failed to provide sufficient preparation and orientation to ensure a safe and orderly discharge for one (Resident #1) of two residents reviewed for facility-initiated discharge. Resident #1 was issued a 30-day notice of discharge for failure to comply with smoking rules, which was then rescinded the next day when she (and her family) was advised she had to leave immediately due to her endangering other residents in the facility. This was after having been provided with 1:1 staff supervision and demonstrating safe smoking practices since. The result was an abrupt, spontaneous discharge to a location 203 miles away from her husband and son/Power of Attorney (POA) which resulted in trauma to the resident and her family.

Inspectors wroteBased on a record review, interviews, and facility policy and procedure review, the facility failed to involve the resident and/or their representative in a discharge plan that considered resident preferences and involved the resident and representative in selecting a post-discharge provider for one (Resident #1) of two residents reviewed for facility-initiated discharges. Failure to involve the resident and her representative in selection of potential discharge locations resulted in an abrupt, spontaneous discharge to a facility 203 miles away from her husband and family member who was her Power of Attorney (POA). As a result, the resident and her family experienced trauma.

Inspectors wroteBased on observations, staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in nonconsensual sexual contact for one (Resident #1) of four residents reviewed for abuse. The facility failed to identify, develop, and implement interventions necessary to protect Resident #1 from nonconsensual sexual contact with Resident #2, who had moderate cognitive impairment and diagnoses including unspecified psychosis, generalized anxiety, and who was independently ambulatory. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial and/or physical harm from Resident #2. [...]

Inspectors wroteBased on a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), interviews with staff, and resident and facility record reviews, the facility failed to implement its policies and procedures to protect vulnerable residents from sexual abuse by failing to 1) Identify sexual abuse following nonconsensual activity between Resident #1 (severe cognitive impairment and independently ambulatory) and Resident #2 (moderate cognitive impairment and independently ambulatory), 2) Protect Resident #1 by providing increased supervision and a room change (as alleged in the facility's response to the incident) to increase the distance between Resident #1 and Resident #2, 3) Initiate staff training on what constituted sexual abuse following the incident, 4) Modify resident care plans to include specific interventions and supervision/monitoring requirements in order to identify [...]

Inspectors wroteBased on observations, staff interviews, resident and facility record reviews, a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), and the facility's 2023 Quality Assurance and Performance Improvement Plan, the facility failed to identify, develop, and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes, and the failure contributed to nonconsensual sexual contact for one (Resident #1) of four residents reviewed for abuse. It also placed all other vulnerable female residents at risk for serious adverse outcomes related to potential sexual abuse from Resident #2. [...]

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility failed to maintain a safe and sanitary living environment for 31 of 103 current residents, as evidenced by water damage in the ceilings from leaks in the roof in four resident rooms (rooms 101, 404, 407, and 408), water damage to the carpet and ceiling tiles in the hallway outside of the rehabilitation gym, missing or damaged floor tiles in seven resident rooms (rooms 205, 403, 404, 407, 408, 410, and 411) and the shower room on the 400 hall, damage to the walls in three resident rooms (rooms [ROOM NUMBER]), a light out in one resident bathroom (room [ROOM NUMBER]), an air conditioning unit unattached from the wall in one resident room (room [ROOM NUMBER]), and a broken window screen in the shower room on the 400 hall.

Inspectors wroteBased on observations, record review and interviews, the facility failed provide sufficient kitchen staff with the appropriate competencies and skills sets to carry out the functions of food and nutrition service. Failure to ensure that dietary staff were trained and knowledgeable about the proper procedures for food safety and sanitation had the potential to negatively impact all residents who received meals from the kitchen.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to treat two (Residents #43 and #52) of three residents with urinary catheter bags, from a total sample of 31 residents, with respect and dignity. The facility failed to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, including refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two (Residents #43 and #28) from a total sample of 31 residents, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Each resident must have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and to address the resident's medical, physical, mental and psychosocial needs. The facility failed to develop a person-centered care plan focus area for Resident #43 regarding her urinary catheter. Resident #43 was one of three residents identified with a urinary catheter. [...]

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #27) of seven residents who relied on supplemental oxygen, from a total of 31 residents sampled, was administered oxygen, consistent with professional standards of practice and the comprehensive person-centered care plan.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. Medication administration observations were conducted with four nurses on all three shifts. There were 25 opportunities for error with three medication errors involving Residents #80 and #27 for a medication error rate of 12%.

Inspectors wroteBased on observations, staff interviews, and medical record review, the facility failed to ensure standard precautions were followed to prevent spread of infections for one (Resident #43) of three residents who relied on a urinary catheter collection bag, from a total sample of 31 residents. The resident's urinary catheter collection bag was allowed to rest directly on the floor.

Inspectors wroteBased on observations, staff interviews, record review and facility policy and procedure review, the facility failed to maintain essential kitchen equipment in safe operating condition by not ensuring proper maintenance of the low temperature dishwashing machine. Failure to ensure clean and sanitized dishware creates the potential for foodborne illness and infection in vulnerable nursing home residents. This failure had the potential to affect every resident who consumed food from the facility's kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to file a grievance on behalf of a resident for one (Resident #30) of 26 residents sampled, and resolve their concerns about a staff member's behavior.