Bay Pointe Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Bay Pointe Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, patternF880Oct 15, 2021

  Based on observation, record review, interviews, policy review, review of the disinfectant label, review of manufacturer's guidelines, and review of Centers for Disease Control and Prevention (CDC) guidelines for COVID-19, the facility failed to: 1. ensure that three of four Licensed Practical Nurses (LPN) (LPN 1, LPN2, and LPN4) on Unit 2 cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the EPA-approved disinfectant's instructions for use when performing fingerstick blood glucose testing (accuchecks) between residents; and 2. […]

• Immediate jeopardy, isolatedF689Feb 27, 2023

  Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to assure a resident's environment remained as free of accident hazards as possible by safely storing green rubbing alcohol to prevent oral use for one (1) of 37 residents (Resident #15), in the survey sample. Immediate Jeopardy (IJ) was called on 2/21/23 at 4:56 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 2/23/23 at 1:11 PM. The scope and severity was lowered to a level 2, pattern. The findings included: Resident #15 was originally admitted to the facility 4/11/16 and readmitted [DATE] after an acute care hospital stay. […]

• No harm, potential for more than minimal, widespreadF756Aug 24, 2023

  Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a Medication Regimen Review (MRR) policy that included required time frames for pharmacist's review and physician's response to the pharmacist's recommendations, potentially affecting all residents but specifically for five of 33 residents in the survey sample; Residents #15, #69, #16, #67 and #39. The findings include: 1. For Resident #15 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. Resident #15 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF641Aug 24, 2023

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for five out of 33 residents in the survey sample, Residents ##11, #62, #57, #32 and #111. The findings include: 1. For Resident #11, the facility staff failed to complete an accurate MDS (minimum data set); annual assessment for anticoagulant use. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/17/23, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. […]

• No harm, potential for more than minimal, patternF656Aug 24, 2023

  Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for seven of 33 residents in the survey sample, Residents #68, #89, #39, #22, #62, #25 and #101. The findings include: 1. For Resident #68 (R68), the facility staff failed to implement the comprehensive care plan to keep their fingernails short. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/2023, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. […]