Baisch Nursing Center

In the surveyor’s words

From the most serious findings on record at Baisch Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Jan 26, 2024

  Based on interview and record review, the facility failed to ensure the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) was complete and reviewed annually. The facility census was 56. Review of the Facility Assessment policy, dated 04/01/19, showed: - A facility assessment will be conducted annually to determine and update our capacity to competently care for and meet the needs of our residents during day-to-day operations including during an emergency; - Once a year and as needed, a designated team will conduct a facility wide assessment to ensure that the resources are available to meet the specific needs of the residents; - The team responsible for conducting, reviewing,… […]

• No harm, potential for more than minimal, widespreadF867Jan 26, 2024

  Based on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's QAPI Principles and Plan, undated, showed: - QAPI will be incorporated into the culture of the facility. We will use data gathered to make decisions and to drive improvement in all areas of our business. The underlying message to everyone working or living in our facility will be that we will take steps to identify, implement, and sustain continuous improvements in all departments. […]

• No harm, potential for more than minimal, widespreadF868Jan 26, 2024

  Based on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's census was 56. Review of the facility's policy, Quality Assurance and Improvement Program (QAPI), dated 04/10/19, showed: - The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents; - The QAPI Committee will include at minimum: the Administrator; Director of Nursing; Medical Director; Activities Director; Social Service Director; Dietary Manager; Housekeeping and Laundry Supervisor; Maintenance Director; Additional Facility Staff; and contracted staff including but not limited to… […]

• No harm, potential for more than minimal, widespreadF881Jan 26, 2024

  Based on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's Antibiotic Stewardship policy, dated 03/26/20, showed: - The purpose is to reduce the use of antibiotics to make sure residents aren't receiving antibiotics unnecessarily; to educate resident, family, and staff on the use of receiving antibiotics unnecessarily; and to track antibiotic use and to make sure that the correct antibiotic is being prescribed; - The nurse will complete the criteria form specific to each individual's clinical symptoms and notify the doctor if it… […]

• No harm, potential for more than minimal, widespreadF882Jan 26, 2024

  Based on interview and record review, the facility failed to designate a qualified individual as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 56. The facility did not provide a policy regarding required primary professional training for the Infection Preventionist. During an interview on 01/25/24 at 2:49 P.M., the Director of Nurses (DON) said she is the IP. She has taken the classes, but hasn't taken the certification test. The facility doesn't have a certified IP. During an interview on 01/26/24 at 6:45 P.M., the Administrator said she would expect the facility to have a certified IP. During an interview on 01/30/24 at 3:45 P.M., the Administrator said the DON has been in the IP role for about two years.