Bailey-Boushay House

In the surveyor’s words

From the most serious findings on record at Bailey-Boushay House, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF577May 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure the survey result binder included the recent recertification survey results that led to citations and plan of corrections for 2 of 3 years (2023 & 2024), reviewed for availability of survey reports. This failure prevented the residents, residents' representatives, and visitors from exercising their right to review past survey results and the facility's plan of corrections. Findings included . Review of the facility policy titled, Availability of Survey Results, updated in April 2025, showed, Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request. […]

• No harm, potential for more than minimal, patternF641May 5, 2025

  Based on interview and record review, the facility failed to accurately assess 4 of 13 residents (Residents 13, 5, 23 & 17), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding opioid (medication to treat pain) use, presence of delusion (false belief), activity interview and insulin (medication/hormone that regulates blood sugar levels) injections placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . […]

• No harm, potential for more than minimal, patternF645May 5, 2025

  RESIDENT 5 Review of Resident 5's Level I PASARR completed on 04/10/2017 showed the diagnosis of psychotic and anxiety disorders were marked in Section I and no referral for Level II evaluation was indicated. Review of Resident 5's Electronic Health Record (EHR) did not show a Level I PASARR was updated and no referral for Level II evaluation was completed. In a joint record review and interview on 05/05/2025 at 10:09 AM with Staff G showed Resident 5's Level I PASARR was completed on 04/10/2017 and SMI indicators were checked. Further joint review of Resident 5's Level I PASARR did not show a referral for Level II evaluation was indicated. Staff G stated that Resident 5 had SMI and referral for a Level II evaluation was not completed. […]

• No harm, potential for more than minimal, patternF732May 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed to reflect the facility's name for 5 of 5 days (04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025 & 05/05/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, updated in November 2022, showed that the information recorded on the form shall include the name of the facility. […]

• No harm, potential for more than minimal, patternF761May 5, 2025

  Based on observation, interview, and record review, the facility failed to appropriately store biologicals (medicines made from living things like proteins that help treat and/or prevent diseases) to maintain the appropriate temperature range for 1 of 1 medication refrigerator (2nd floor Medication Refrigerator), and failed to ensure medical supplies were labeled with expiration dates for 1 of 2 medication carts (West 3 Medication Cart), reviewed for medication storage and labeling. […]