Bywood East Health Care

In the surveyor’s words

From the most serious findings on record at Bywood East Health Care, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 7, 2022

  Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19 to prevent or minimize the transmission of COVID-19 related to use of personal protective equipment (PPE) and the disinfection of multi-resident use equipment from a known COVID-19 positive residents' (R47 and R25) room (room [ROOM NUMBER]) to a non-COVID-19 positive residents' (R7 and R46) room (room [ROOM NUMBER]). The facility's failure resulted in an Immediate Jeopardy (IJ) situation for all 38 residents who resided on the locked housing unit. […]

• Immediate jeopardy, widespreadF886Feb 7, 2022

  Based on interview and record review, the facility failed to ensure all 86 residents and 87 staff were tested for COVID-19 folowing an outbreak regardless, immediately and, if negative, again 5-7 days later. This deficient practice had the potential to affect all 82 non-COVID-19 positive residents, as well as staff, and visitors in the facility. The IJ began on 12/15/21, when a staff member tested positive for COVID-19 and the facility failed to offer or conduct tests for COVID-19 for all residents, according to Center for Disease (CDC) guidelines. The Administrator and director of nursing (DON) were notified of the IJ on 2/4/22, at 1:19 p.m. The IJ was removed on 2/7/22, at 12:39 p.m. […]

• Immediate jeopardy, isolatedF805Dec 15, 2025

  Based on interview and document review the facility failed to provide a resident's prescribed therapeutic diet when on 11/17/25, a registered nurse (RN)-A assisted R3 to purchase a sticky bun from the vending machine at the facility because he was unable to do so himself for 1 of 3 residents (R3) reviewed for food and drink. While eating the sticky bun R3 started to choke and went unresponsive, cardiopulmonary resuscitation (CPR) was started and R3 was transferred to the hospital where he subsequently died on [DATE].The immediate jeopardy began on 11/17/25 when RN-A purchased a non-pureed item out of a vending machine for R3, R3 choked on the item resulting in his death was identified on 11/17/25. […]

• Immediate jeopardy, isolatedF600Aug 27, 2025

  Based on observation, interview and document review the facility failed to ensure residents were protected from resident-to-resident abuse for 2 of 2 residents (R3 and R4) who were in a verbal and physical altercation which resulted a thoracic (T9) fracture with facial injuries for R4 and a swollen, bruised hand for R3. This resulted in an Immediate Jeopardy (IJ) for both R3 and R4.The IJ began on 8/14/25 at 10:45 p.m., when R3 and R4 had a verbal altercation, were separated by staff with one verbal redirection towards R3, but no other behavioral interventions were implemented despite a significant history of physical altercations for both residents, leading to R3 seeking R4 out again, re-engaging in the verbal altercation before starting a physical altercation which resulted in R4 needing… […]

• Immediate jeopardy, isolatedF689Aug 27, 2025

  Based on observation, intervention and document review the facility failed to ensure a safe environment and prevent fire hazards for 2 of 2 residents (R5 and R6) when residents were found to be smoking in resident rooms with staff awareness. This resulted in an immediate jeopardy (IJ) for R5 and R6 and could lead to serious harm for all residents, staff, and visitors at the facility. The IJ began on [DATE] at. 4:54 p.m., when a strong smell of cigarette smoke was noted on the third floor near the elevator and trained medication aide (TMA)-A and TMA-B stated the odor was coming from room [ROOM NUMBER] (R6's room). R5 was observed in room [ROOM NUMBER] and was asked to leave by staff. During interview, R5 stated he was in the room and had just been smoking. […]