Bath Manor Special Care Centre

In the surveyor’s words

From the most serious findings on record at Bath Manor Special Care Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 8, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of a police report and medical examiner information, personnel file review, review of narcotic/controlled drug sheets, review of Medscape drug reference information, facility policy review and interviews, the facility failed to ensure Resident #117 was free from a significant medication error and failed to ensure the error was reported immediately so that timely and appropriate medical intervention could be provided. This resulted in Immediate Jeopardy and actual harm/death of Resident #117 when on [DATE] at approximately 6:56 A.M. […]

• Actual harm, isolatedF689Jun 6, 2024

  Based on observation, interview, record review, facility Self-Reported Incident review, hospital record review, and review of the facility policy the facility failed to ensure a comprehensive fall risk assessment with individualized interventions was in place for Resident #83 and failed to timely assess and properly treat the resident after a fall. Actual harm occurred on 04/29/24 when Resident #83, who was at risk for falls did not have individualized interventions in place to address the risk, fell in her room and was not thoroughly assessed before being returned to bed. This resulted in the resident experiencing severe pain to her leg and a delay in immediate treatment. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2025

  Based on kitchen observation, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents receiving meals from the kitchen. The facility identified six Residents (#30, #57, #60, #75, #119, and #269) as receiving nothing by mouth (NPO). The facility census was 112. Findings include: Observations on 05/05/25 (Monday) at 9:03 A.M. of the facility kitchen with Food and Nutrition Services Director (FNSD) #633 revealed in the reach-in refrigerator near the steam table there was two undated or labeled salads and approximately 10 bagged sandwiches without labels or dates. FNSD #633 indicated they usually disposed of salads and sandwiches after the weekend. […]

• No harm, potential for more than minimal, widespreadF880May 13, 2025

  Based on record review, observation, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented as required. This had the potential to affect all residents residing in the facility. Facility census was 112. Findings include: Review of Resident #269 medical record revealed the resident was admitted on [DATE] with diagnoses of Parkinsonism, primary pulmonary hypertension, protein-calorie malnutrition, acute respiratory failure, other rheumatic mitral valve diseases, pressure ulcer stage 4, history of malignant neoplasm of prostate, dysphagia and muscle weakness. Further review of the medical record revealed an order dated 04/18/25 for enhanced barrier precautions (EBP). Observation on 05/07/25 at 11:34 A.M. […]

• No harm, potential for more than minimal, widespreadF812Dec 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all residents who received meals from the kitchen. The facility identified 12 residents (#2, #13, #15, #41, #62, #77, #80, #88, #94, #96, #420, and #670) that had a nothing by mouth (NPO) diet. The facility census was 123. Findings include: Observations of the facility kitchen on 12/04/23 at 8:22 A.M. revealed a fan located by the ice machine covered in dust. The ice machine had a white colored build up at the gaskets and the down sides. There was an unidentified brown substance on the inside of the ice machine. […]