Goodwin House Bailey's Crossroads

In the surveyor’s words

From the most serious findings on record at Goodwin House Bailey's Crossroads, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF692Aug 21, 2024

  Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for one of 28 residents, Resident #53. The findings include: The facility failed to provide monitoring for fluid restriction and intake for Resident #53. Resident #53 was admitted to the facility on [DATE] with diagnosis that included but were not limited to toxic hyponatremia, CHF (congestive heart failure), CKD (chronic kidney disease and atrial fibrillation. […]

• No harm, potential for more than minimal, patternF812Aug 21, 2024

  Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen in a sanitary manner. The findings include: On 8/20/24 at 7:25 AM, an observation was conducted in the main kitchen. Two employees were observed coming from the kitchen without hair nets, OSM (other staff member) #3, the cook and OSM #5, dining services. When told I was there for the kitchen inspection and requested a hair net, OSM #3, the cook, went back into the kitchen to obtain a hair net. OSM #3 put a hairnet on at this time. Hair nets were located inside the kitchen and around a corner near another entrance, but not outside of the kitchen area. […]

• No harm, potential for more than minimal, patternF812Apr 26, 2023

  Based on observation, staff interview and facility document review, it was determined the facility staff failed to store food in a sanitary manner in one of one main kitchens. The findings include: Observation was made of the main kitchen on 4/25/2023 at 11:00 a.m. accompanied by OSM (other staff member) #1, the registered dietitian/manager, and OSM #2, the executive chef. The walk-in freezer contained a plastic box approximately two feet long and one foot wide. It contained chopped frozen carrots. There were two blue plastic bags in the box. The carrots were sitting in the box, not in plastic. There was no lid on the box so the carrots in the box were exposed to air. OSM #1 stated she believed they had just taken some carrots out of the box for the lunch meal soup. […]

• No harm, potential for more than minimal, isolatedF554Aug 21, 2024

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was safe to self-administer a medication for one of 28 residents in the survey sample, Resident #169. The findings include: For Resident #169 (R169), the facility staff failed to complete an assessment to determine if the resident was safe to self-administer a nebulizer medication. A review of R169's clinical record revealed a physician's order dated 8/13/24 for ipratropium 0.5 mg (milligrams)-albuterol (1) 3 mg- 3 ml (milliliters) via nebulization two times per day for aspiration pneumonia. On 8/20/24 at 8:56 a.m., R169 was observed holding a mask to his face and self-administering a nebulizer medication. […]

• No harm, potential for more than minimal, isolatedF655Aug 21, 2024

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the baseline care plan for one of 28 residents in the survey sample, Resident #169. The findings include: For Resident #169, the facility staff failed to implement the resident's baseline care plan for a fall mat. R169's baseline care plan dated 8/9/24 documented, (R169) will remain safe during treatments and care while in the facility. (A) (R169) needs these safety measures: Floor Mat x1 . A review of R169's clinical record revealed a physician's order dated 8/9/24 that documented, Fall mat x1. On 8/20/24 at 8:56 a.m., 8/20/24 at 3:39 p.m., and 8/21/24 at 8:47 a.m., R169 was observed lying in bed. There was no fall mat down on either side of the bed. […]