Barbour Court Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Barbour Court Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 8, 2022

  Based on observations, interviews with facility staff and the physician and record review the facility failed to prevent a severely cognitively impaired resident (Resident #102) from exiting the facility without supervision for 1 of 2 residents reviewed for accidents. Receptionist #1 let Resident #102 out of the locked front door, without notifying nursing staff and he was left outside unattended and out of visual sight of the facility staff. There was a high likelihood of Resident #102 suffering serious harm. The findings included: Resident #102 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF641Feb 26, 2026

  Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of medications (Resident #8, Resident #4, and Resident #5) and Pneumococcal Vaccine (Resident #18). This was for 4 of 28 residents whose MDS assessments were reviewed.Findings included:a. Resident #8 was admitted to the facility on [DATE].Resident #8's physician orders included Novolog (a rapid acting insulin) injection solution 100 units/milliliter inject 10 units subcutaneously (beneath the skin) with meals. […]

• No harm, potential for more than minimal, patternF578Nov 15, 2024

  Based on record review and resident and staff interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record (Resident #10) and failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #18, #51, and #84). This was for 4 of 17 residents reviewed for advance directives. The findings included: a. A review of the facility's policy titled Documentation of Advanced Directives dated 2/2007 revealed in part It is the policy of the facility to document in the residents' medical record whether or not the resident has executed an advanced directive. […]

• No harm, potential for more than minimal, patternF657Nov 15, 2024

  Based on record review, resident, Resident Representative (RR) and staff interviews, the facility failed to conduct care plan meetings or invite residents to their care plan meetings for 4 of 9 residents reviewed for care plans (Residents #39, #40, #100, and 117). Findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and aphasia (unable to speak). The quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #39 was severely cognitively impaired. An interview on 11/12/24 at 11:13 AM with Resident #39's Resident Representative (RR) revealed she had not been invited to a care plan meeting since Resident #39's admission. She stated she would like to attend a care plan meeting. […]

• No harm, potential for more than minimal, patternF657Apr 8, 2022

  Based on record review and staff, resident, and resident representative interviews the facility failed to invite a resident or resident representative to participate in the development or revision of the care plan for 5 of 8 residents reviewed for care plan meetings (Resident #91, Resident #16, Resident #46, Resident #97, and Resident #43). Findings included: 1. Resident #91 was admitted to the facility on [DATE]. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #91's Minimum Data Set assessment dated [DATE] revealed the resident was assessed as cognitively intact. […]