Bay Vista Healthcare & Wellness Centre, LP

In the surveyor’s words

From the most serious findings on record at Bay Vista Healthcare & Wellness Centre, LP, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jul 19, 2021

  Based on interview, and record review, the facility failed to follow the plan of care to keep blood sugar levels in control with stable numbers for one of one resident (Resident 45), who was diagnosed with diabetes (abnormal blood sugar levels) by failing to: a. Follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in the physician not notified when Resident 45's blood sugar levels reached 400 mg/dL and above per the sliding scale (the dose of insulin ([MEDICATION(S)], medication given to lower blood sugar level), to be given depending on the blood sugar results) for total of 16 times in May 2021, 15 times in June 2021, and 20 times in July 2021 . b. […]

• Immediate jeopardy, patternF756Jul 19, 2021

  Based on interview and record review, the facility failed to address the Pharmacist Consultant (PC) irregularities and recommendations found on 5/2021 and 6/2021 during the Medication Regimen Review ([MRR] a review of all medications the patient is currently using in order to identify potential problems) for one of 15 residents (Resident 45). Resident 45, who was diabetic (abnormal blood sugar levels), experienced 48 instances of high blood sugar levels greater than 400 milligram/deciliter ([mg/dL] Normal Reference Range [NRR] from 70-130 mg/dL), which the PC recommended to report to the physician to adjust drug therapy, were not addressed by the attending physician and the Director of Nursing (DON), to ensure the irregularities were acted upon. […]

• Actual harm, isolatedF689Apr 4, 2025

  Based on observation, interview and record review, the facility failed to ensure the resident, who had a history of banging her head on the wall, did not banged her head on the wall and sustained an injury for one of three sampled resident (Resident 1). The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA) 1, who was assigned to provide Resident 1 with 1:1 (a constant observation provided by a care giver/sitter) supervision for safety, prevented Resident 1 from walking towards the wall and start banging her head on the wall. 2. Ensure CNA 1 was informed and had knowledge of Resident 1's behavior of banging her head on the wall. 3. […]

• Actual harm, isolatedF600Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was not physically assaulted by another resident (Resident 2). This deficient practice resulted in Resident 1 sustaining a laceration (a deep, jagged tear or cut in the skin, often caused by a sharp object or blunt trauma, resulting in an irregular wound that could bleed significantly) to his right hand between his right thumb and right pointer finger, that required eight sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) and abrasions (a minor injury to the skin that occurs when the skin is rubbed or scraped) to his right forearm, right knee and left knee. […]

• Actual harm, isolatedF600May 13, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not subjected to a physical abuse by Resident 2. The facility failed to: 1. Ensure Resident 1, who had a history of aggressive behavior toward residents and staff and was sent out to a general acute care hospital (GACH) on 5150 (temporary, involuntary psychiatric commitment of residents who present a danger to themselves or others due to signs of mental illness) hold on 4/18/2024, was not placed in the same room with Resident 2 upon re-admission to the facility on [DATE]. 2. Ensure staff followed Resident 2's care plan titled, Alleged altercation per another roommate on 4/11/2024, to prevent Resident 2 altercations with Resident 1 on 4/27/2024. 3. […]