Cherry Point Bay Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Mar 5, 2024

  Based on record review and staff, Nurse Practitioner (NP) and Physician interviews the facility failed to notify the physician immediately when Resident #1 had a fall from the shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) headfirst to the floor of the shower room on 2/01/24 at approximately 2:50 AM. Resident #1 sustained a small bruise to the back of her head and an abrasion to her lower back area and was at risk for further injury from head trauma due to a history left hemicraniectomy (surgical procedure where a large flap of the skull is removed) and seizures. On 2/01/24 at approximately 10:00 AM the resident had a change in neurological status with nystagmus (repetitive, uncontrolled eye movement) observed. […]

• Immediate jeopardy, isolatedF689Mar 5, 2024

  Based on record review, observation, and staff, Nurse Practitioner (NP), and Physician interviews, the facility failed to follow the manufacturer's instructions for the use of a mobile shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) and to provide care safely for 1 of 1 resident reviewed for supervision to prevent accidents. On 2/01/24 Nursing Assistant (NA) #1 transported Resident #1 to the shower room via the shower bed without utilizing the locking pins that secured the head and the foot of the bed in place. While transporting the resident to the shower room the foot of the shower bed released and dropped toward to the floor. NA #1 did not cease the transport. […]

• Immediate jeopardy, isolatedF726Mar 5, 2024

  Based on observations, record review, staff, Nurse Practitioner (NP), and Physician interviews the facility failed to train Nursing Assistants (NAs) and verify competency for the safe operation of a foldable shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) for 1 of 1 NA (NA #1) reviewed. NA #1 was unaware that the shower bed required locking pins to be inserted to secure the head of the bed and the foot of bed to prevent the shower bed from folding. On 2/01/24 NA #1 transported Resident #1 to the shower room via the shower bed without utilizing the locking pins. While transporting the resident to the shower room the foot of the shower bed released and dropped toward to the floor. […]

• Immediate jeopardy, isolatedF689Apr 20, 2023

  Based on observations, record review, staff and Physician interviews the facility failed to provide a safe transfer by mechanical lift for a dependent resident (Resident #33) on 04/07/23 when Nurse Aide (NA) #11 used an extra-large sling instead of the medium sized sling the resident was assessed to require. The resident fell out of the sling during the transfer hitting her head on the lift and on the floor. She sustained a laceration to the back of her head with bleeding, she required hospital treatment and 3 staples for the laceration, and she suffered pain from the injury. The facility also failed to prevent a cognitively impaired resident (Resident #39) with known exit seeking behaviors from exiting the facility unsupervised. […]

• No harm, potential for more than minimal, patternF812Jul 11, 2024

  Based on observation and staff interviews the facility failed to label and date foods stored in 1 of 1 nourishment refrigerator located at the central nurse's station. This practice had the potential to affect food served to residents. Findings included: During an observation of the nourishment refrigerator located at the central nurse's station on 7/9/24 at 2:30 pm with the Certified Dietary Manager (CDM) present multiple food items were observed unlabeled without open or discard date. In addtion, a typed sign was observed on the outside of the refrigerator that read in part: label and date food items with date opened and discard 3 days after opening of non-consumed foods. a. One white fast food paper bag with a partially consumed wrapped sandwich that was hard to the touch. […]