Bailey Creek Health and Rehab

In the surveyor’s words

From the most serious findings on record at Bailey Creek Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689May 14, 2021

  Based on observation, record review, and interview, the facility failed to ensure a planned fall prevention intervention was consistently implemented to prevent a fall with injury for 1 (Resident #30) of 6 (Residents #15, #17, #27, #30, #32, #62) case mix residents who had a history of falls in the past 90 days. This failed practice resulted in past noncompliance at actual harm for Resident #30, who fell and sustained a fractured proximal tibia and fibula, and had the potential to cause more than minimal harm for 12 residents who had falls in the past 90 days, according to a list provided by the Director of Nursing (DON) on 5/14/21 at 7:50 a.m. The findings are: Resident #30 had diagnoses of [CONDITION(S)], Cognitive Communication Deficit, Muscle Weakness and Lack of Coordination. […]

• No harm, potential for more than minimal, widespreadF812Sep 6, 2024

  Based on observation, interview, and facility policy review, the facility failed to ensure the ice scoop holder was maintained in clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the freezer were sealed to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to prevent potential cross contamination of food and clean dishes for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 9/4/24 at 3:20 PM, the following observations were made on the spice rack above the food preparation counter: a. A plastic container of oregano with best by date of 5/24/2024. b. […]

• No harm, potential for more than minimal, widespreadF812Jul 29, 2022

  Based on observation, record review and interview, the facility failed to ensure staff washed their hands before handling clean equipment to minimize the risk of food borne illness for the residents who received meals from 1 of 1 kitchen; food items stored in the refrigerator and freezer were covered or sealed to prevent the potential for cross contamination and/or food borne illness for residents who received meals from 1 of 1 kitchen; failed to keep kitchen vents clean to provide a clean and sanitary environment for food preparation and prevent the potential food borne illness for residents who received meals from 1 of 1 kitchen; floors, dish washer and kitchen, walls, door frames and baseboards were free of debris, dirt, grease, grime, stains, and spills; failed to ensure an ice scoop… […]

• No harm, potential for more than minimal, widespreadF812May 14, 2021

  Based on observation and interview, the facility failed to ensure plastic containers of foods items stored in the refrigerator were promptly removed and discarded, and the refrigerator was kept clean to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 63 residents who received meals from the kitchen as documented on a list provided by the Director of Nurse (DON) on 5/14/21. The findings are: 1. On 5/10/21 at 11:56 AM, in the refrigerator, there was applesauce in a clear container covered with a clear plastic wrap and dated 4/19. There was a clear container with Jell-O dated 5/02. There was a clear container with mandarin oranges with a label dated 4/7. […]

• No harm, potential for more than minimal, patternF656Apr 9, 2026

  Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to update the Care Plans for two (Resident #54 and Resident #99) of four residents reviewed.The findings include:Resident #54A review of Resident #54's admission Record revealed the facility initially admitted the resident on 06/04/2020, with diagnoses which included unsteadiness on feet, muscle weakness, malnutrition, muscle wasting and atrophy, and a fall from a non-moving wheelchair.A review of Resident #54's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/02/2026, revealed a Brief Interview of Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. […]