Baypointe Physical Rehabilitation Center

Baypointe Physical Rehabilitation Center

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About Baypointe Physical Rehabilitation Center

Baypointe Physical Rehabilitation Center is a for profit, 169-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of  Brockton, Stoughton,  Randolph, Holbrook, Abington, Easton, Whitman, East Bridgewater, Canton, Sharon, Rockland, Bridgewater,  Hanson, Mansfield, Braintree, and the other towns in and surrounding Bristol County, Massachusetts.

Baypointe Physical Rehabilitation Center
50 Christy’s Pl,
Brockton, MA 02301

Phone: (508) 580-6800
Website: http://www.baypointerehab.com/baypointe/

CMS Star Quality Rating

 Baypointe Physical Rehabilitation CenterThe Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Baypointe Physical Rehabilitation Center in Brockton, Massachusetts received a rating of 3 out of 5 stars.

Performance Area Rating
Overall Rating 3 out of 5 (Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Baypointe Physical Rehabilitation Center

The Federal Government has not fined Baypointe Physical Rehabilitation Center in the last 3 years.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Baypointe Physical Rehabilitation Center committed the following offenses:

 

Failed to let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to properly obtain consents for the use of [MEDICAL CONDITION] medications that included the dose of the medications for 3 ( #4, #6 and #12) of 25 sampled residents.

Findings include:

[MEDICAL CONDITION] medications included the dose of the medication. Resident #4 was readmitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. Record review on 12/6/16 indicated the Resident was receiving the following medications:

[REDACTED] -Resperdone 0.5 twice a day (anti-psychotic)
-[MEDICATION NAME] 15 mg every day (anti-depressant)
-[MEDICATION NAME] 25 mg (1/2 tablet 12.5) every 6 hours as needed (anti-depressant)

Review of Minimum Data Set assessment completed 11/25/16 indicated Resident #4 had a health care proxy that was invoked on 6/1/16. The health care agent had signed consents for the [MEDICAL CONDITION] medications (5/2016) that had not included the doses for the medications being administered. On 12/6/16, the DON said the facility failed to implement the newer consent forms that included the dose range of each medication which requires a consent to administer. The updated consent forms for Resident #4 were completed on 12/7/16.

2. For Resident #6, the facility failed to ensure the consent obtained for the use of [MEDICAL CONDITION] medications included the dose of the medication. Resident #6 was readmitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. Clinical record review on 12/6/16 indicated Resident #6 was receiving the following medications:

[REDACTED] -[MEDICATION NAME] 50 mg (1/2 tab 25 mg) every evening (anti-depressant)
-[MEDICATION NAME] 12.5 mg every evening and as needed every 8 hours for anxiety (anti-anxiety)
-[MEDICATION NAME] 5 mg every evening (anti-psychotic)
-[MEDICATION NAME] 15 mg every day (sedative, anti-depressant)

Review of the Minimum Data Set assessment completed 11/25/16, indicated Resident #6 had a health care proxy that was invoked on 5/25/16. The health care agent had signed consents for the [MEDICAL CONDITION] medications (5/2016). Review of the consent forms did not included the doses for the medications being administered. On 12/6/16, the DON said the facility failed to implement the newer consent forms that included the dose range of each medication and which required signed consents to administer.

3. For Resident #12, the facility failed to ensure the consent obtained for the use of [MEDICAL CONDITION] medications included the dose of the medication. Resident #12 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment completed 10/20/16, indicated Resident #6 had significant cognitive deficits and was dependent in all aspects of his/her activities of daily living. The Resident’s health care proxy was invoked on 10/6/16. Clinical record review on 12/8/16 indicated Resident #12 was receiving [MEDICATION NAME] (anti-anxiety) 0.25 ml every 2 hours sublingual. Although the health care agent had signed consent for the [MEDICAL CONDITION] medication (10/6/16), review of the consent form did not included the dose for the medication being administered.

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review of 1 (#15) of 3 Residents who had Peripherally Inserted Central Catheters (PICC’s) from a total sample of 25 Residents, the facility failed to ensure that either the physician or nurse practitioner was notified of discrepancies in external catheter length from the baseline measurement.

Findings include:

Resident #15 was admitted to the facility in 5/2010 and had [DIAGNOSES REDACTED]. The medical record was reviewed on 12/7/16. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/18/16, indicated that Resident #15 was cognitively intact, required extensive assistance of staff with all activities of daily living and was receiving intravenous antibiotic therapy. Review of physician’s orders [REDACTED].#15 was prescribed the antibiotics, Meropenam and [MEDICATION NAME] (initiated 8/16/16), to be administered via a PICC line. The physician’s orders [REDACTED]. Review of the facility’s policy for the care of central catheters indicated that the external length of the catheter was to be measured weekly during the weekly dressing change to assess for migration and discrepancies were to be reported to the physician.

Review of the 10/2016, 11/2016 and 12/2016 Medication Administration Records (MAR), indicated that the external catheter lengths, as measured by the nurse were as follows:

0 cm on 10/4/16
0 cm on 10/11/16
1.5 cm on 10/1/16
2 cm on 10/25/16
2 cm on 11/1/16
2 cm on 11/15/16
2 cm on 11/22/16
2 cm on 12/6/16

All measurements taken during the month of October, November and December were different from the baseline measurement of 3 cm. Further review of the medical record failed to indicate that either the physician or nurse practitioner was notified of the discrepancies. Per the Infusion Nurses Society’s Infusion Nursing Standards of Practice 2016, the nurse should notify the physician or appropriate delegate immediately of any signs or symptoms related to central venous access device malposition and obtain orders for diagnostic procedures. Unit Manager #3 was interviewed on 12/7/16 at 11:05 A.M. Unit Manager #3 said that no staff person reported the change to the attending physician or nurse practitioner.

Failed to determine if it is safe for the resident to self-administer drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and observations, the facility failed to ensure the medical plan of care for self administration of medications was implemented for 3 Residents (#12, #13 and #14) out of a total sample of 25 Residents and for 1 non-sampled resident (NS #11).

Findings include:

Review of the facility policy for self administration of medications indicated the following:
-The Resident will be assessed for cognitive, physical, and visual ability to carry out this responsibility, during the care planning process.
-The interdisciplinary team determines the Resident’s ability to self-administer medications by means of a skilled assessment on a quarterly basis.

1. For Resident #13, the facility failed to determine the resident’s ability to self administer medications and failed to conduct intermittent assessment to determine the Resident’s ongoing capabilities, and failed to ensure the manner in which the bedside medications were stored to prevent access by other residents. Resident #13 had been admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set Assessment ((MDS) dated [DATE], indicated the Resident scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status) indicating the Resident’s cognitive status was not impaired.

On 12/6/16 at 8:00 A.M., the Surveyor observed three prescription medications on the bedside table. The medications included [MEDICATION NAME] (corticosteroid that is used to treat nasal disorders), ProAir HFA [MEDICATION NAME] sulfate (opens the airway in the lungs) and saline mist (treats dry and irritated nasal passages). Unit Manager #2 (UM #2) was present at the time of the observation and said the Resident had been assessed for self administration and that it was okay that the medications were being stored on the night table. Resident’s #13 medical record was reviewed on 12/7/16. Review of the physician orders included [MEDICATION NAME] 50 mcg, 2 sprays each nostril, daily at 9:00 A.M. (may be kept at the bedside) and the ProAir 90 mcg, 2 puffs, every 4 hours as needed (may be kept at the bedside). However, the order for the saline mist 0.65%, 1 spray each nostril, every hour, as needed, dated as prescribed by the physician on 9/19/16 did not indicate that the Resident could self administer or keep the medication at the bedside.

Review of the Self Administration of Medications Informed Consent and assessment dated [DATE], included a self administration assessment for the [MEDICATION NAME] and the ProAir, but not for the nasal spray. The record failed to indicate that any additional assessments had been conducted following the initial assessment and there was no evidence the assessment included the manner in which the medications would be stored. Observation of Resident #13’s room on 12/7/16 at 2:00 P.M. included the 3 medications (previously listed above) on the bedside table, and the Resident was not in the room. On 12/9/16 at 11:00 A.M., the medications were on the bedside table and Resident #13 said that he/she kept the medications on the night table, but because of survey inspection he/she has to put them in the draw of the bedside table. The Resident said this upset him/her because it was something else that he/ she had to do and it disrupted his/her day. During interview on 12/9/16 at 12:00 P.M. UM #2 confirmed that the nasal spray had not been assessed and there was no complete physician order for [REDACTED].

2. For Resident #14, the facility had not obtained nor completed an assessment for self administration of medications. Resident #14 was admitted to the facility in 9/2016 and had [DIAGNOSES REDACTED]. Review of the recent quarterly MDS dated [DATE], indicated the Resident scored a 15 out 15 on his/her BIMS, indicating no cognitive losses and required extensive assistance in all areas of his/her activities of daily living. On 12/6/16 at 8:00 A.M., the over the counter medications Ben-Gay ([MEDICATION NAME] heat rub), Vicks vapor rub (over the counter topical decongestant) and a bottle of nasal spray were observed on the tray table next to the Resident. UM #2 grabbed the nasal spray off the table and left the room, leaving the Ben-Gay and Vicks. UM #2 confirmed with the medication nurse that the Resident did not have an order for [REDACTED]. Record review on 12/7/18 confirmed that there were no physician orders, consents or assessments completed for the over the counter medications observed in the Resident #14’s room.

3. For Resident #12, the facility failed to ensure that they completed and obtained physician orders, consents and assessments for self administration of medication. Resident #12 was admitted in 10/2016 and had [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], indicated the Resident had significant cognitive deficits and was dependent in all aspects of his/her activities of daily living.

On 12/6/16 at 10:30 A.M. and 12/8/16 at 9:30 A.M., an over the counter medication was observed by Surveyor in the open draw of the Resident’s bedside table. The medication was a topical patch called Salonpas (topical pain patches). Record review on 12/8/16 failed to indicated a physician order, consent or an assessment for self administration. Unit Manager #3 said on 12/8/16 at 9:30 A.M. she thought the Salonpas belonged to the Resident’s family member.

4. For Non Sampled Resident #11 (NS #11), the facility failed to ensure that they completed and obtained physician orders, consents, assessments for self administration of medication.

NS #11 had recently been admitted to the facility. On 12/6/16 at 8:00 A.M., UM #2 said the Resident had [DIAGNOSES REDACTED]. NS #11 said that he/she was active in his/her care and was very health conscious. NS #11 was observed during the initial tour on 12/6/16 at 8:00 A.M. During the tour, the Surveyor observed a bottle of over the counter vitamins ([MEDICATION NAME]) on the tray table. Unit Manager #2 (UM #2) said that the Resident’s family often brought in different vitamins and she said that she had told both the Resident and the family not to do so. She said that the Resident did have prescribed vitamins and did not know why the family continued to bring in more.

A brief record review on 12/6/16 failed to indicated a physician order, consent or an assessment for self administration.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Based on review of the facility grievance log and staff interview, the facility failed to ensure that Residents were not subjected to abuse or mistreatment, that allegations of abuse or mistreatment were immediately investigated, that immediate action was taken to protect Residents from potential abuse during the investigation and that allegations of abuse and mistreatment were immediately reported to the Administrator and to the State Agency for 9 Non Sampled (NS) Residents (NS #1, NS #2, NS #3, NS #4, NS #5, NS #6, NS #7, NS #8, NS #9) out of a total sample of 25 Residents.

Findings include:

A review of the facility’s Abuse Program policy (last reviewed 12/6/16), indicated that any complaint of, observation of, or suspicion of Resident abuse, mistreatment or neglect will be reported to the Department of Public Health within 24 hours by the Administrator or designee. The facility failed to immediately report the following allegations of mistreatment to the Department of Public Health (DPH) as required by State statute:

1. Review of the grievance form dated 4/1/16, indicated that NS #1 reported an inappropriate comment was made to him/her by a CNA on 3/30/16 during the 11-7 shift when she was responding to his/her call light. The grievance indicated that the CNA told the Resident to stop calling for the same thing in an inappropriate tone. Although the facility initiated an investigation, the allegation by NS#1 was not reported.

2. Review of the grievance form dated 4/7/16, indicated that NS #2 and his/her daughter reported that on 4/6/16, a CNA made statements to the Resident telling him/or her to get into bed on your own, I saw you standing in the bathroom, so you can get into the bed and you can sit in that chair until midnight. Although the facility initiated an investigation, the allegation by NS#2’s family was not reported.

3. Review of the grievance form dated 6/2/16, indicated that NS #3 reported that a CNA was rough and hurt him/her during care on 5/31/16 on the 3-11 shift. Although the facility initiated an investigation of the allegation by NS #3 it was not reported.

4. Review of a letter dated 7/12/16, submitted by the Ombudsman indicated that NS #4 reported to her that, when responding to the call light, a CNA on the 11-7 shift spoke to him/her in a disrespectful manner. The report also indicated that despite the Resident being a fall risk, he/she was left alone in the bathroom three times. Although the facility initiated an investigation, the allegation by NS#4, was not reported.

5. Review of a letter dated 7/12/16, submitted by the Ombudsman indicated that NS #5 reported to her that a CNA spoke to him/her in a disrespectful manner. The report indicated the CNA said to the Resident that he/she had let yourself go and Look at you .you have no teeth. The facility initiated an investigation but failed to report the allegation.

6. Review of the grievance form dated 7/26/16, indicated that on 7/25/16, NS #6’s health care proxy reported that she was told by the Resident that a male nurse had been treating him/her a little rough during care and had observed bruising to the Resident’s arms. Although an investigation was initiated, the NS#6’s allegation of rough treatment was not reported.

7. Review of the grievance form dated 8/31/16, indicated that on 8/30/16, NS #7 reported that when he/she uses the call light, it is not answered for at least one hour. On 8/30/16 when the CNA responded to the call light and the Resident requested assistance to go to the bathroom, the CNA told the Resident to go in his/her brief. Although an investigation was initiated, for NS#7’s allegation of disrespectful treatment was not reported.

8. Review of the grievance form dated 9/14/16, indicated NS #8 told his/her daughter that: – on on 9/13/16 during the 11-7 shift, he/she had used to call light because he/she needed assistance to go to the bathroom. When the CNA responded approximately 30-45 minutes later, the CNA said to him/her in a disrespectful manner, You don’t know what you want. – NS #8 is continent, but staff put diapers on the Resident during the overnight shift. Although an investigation was initiated, the allegation was not reported.

9. Review of the grievance form dated 9/15/16, indicated that on 9/15/16, NS #9 reported that a nurse administering medications refused to tell the Resident what his/her medications were and told the Resident to Just take them. The Resident reported that he/she asked the nurse again to explain what the medications were, the nurse refused and said, You want a white nurse? NS #9 reported being upset and offended by the nurse’s comments. Although there was an initial investigation, the facility failed to report. During interviews with facility social workers on 12/9/16 at 2:30 P.M., the social workers said that the facility tracks various incidents that occur that they are made aware of. For instance, missing clothing may or may not rise to the level of a grievance and be documented. In some cases the missing items are reported and staff try to locate the items; when the items can not be located and the resident / family submit a grievance, then it would be documented in the grievance log.

Allegations of resident mistreatment are followed up with interviews of residents and investigations are performed based on the nature of the complaint. The three social workers (Director of Social Services, Social Worker #1 and Social Worker #2) all cover a specific resident unit. All the documented incidents are submitted to the Administrator and Director of Nurses for further review, including obtaining statements and action such as reporting. The facility’s team discuss issues at morning meetings as well. The social workers said that reporting of allegations of abuse, mistreatment, misappropriation was done by the Administrator and/or Director of Nurses.

Further interview on 12/9/16 at 3:20 P.M., the Administrator said that the facility conducts investigations of allegations, including interviews and observations as necessary and will often determine that an incident was not intentional or that they could not validate that harmful action occurred. Therefore, it would not be considered reportable to the State. Often re-education is provided to staff, or if a resident/family are satisfied with our investigation and response to an issue, it is documented as resolved. The Administrator said at times comments that could be viewed as inappropriate are made, so we look at the whole incident not to suspend individuals unnecessarily. Additionally, the facility failed to immediately report the following allegations of misappropriation of property to the Department of Public Health (DPH) as required by State statute:

1. Review of the grievance form dated 5/27/16, indicated that on 5/26/16, NS #1 reported missing $99.

2. Review of the grievance form dated 6/2/16, indicated that NS #3 reported a missing pocketbook which contained $21.

Follow-up interview regarding incidents of missing money, the Administrator said that for NS #1, it was uncertain that the resident had that specific amount of money and some of the cash was located (unknown date) in the laundry, so the facility investigated, recovered a portion of the total amount claimed as missing and it was not reported. For NS #3, the missing money and purse was not reported, but compensation to replace the items was offered.

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive, person centered plan of care for 2 Residents (#7 and #9) from a total sample of 25 Residents, that integrated (1) the facility’s consultant psychotherapist’s interventions and goals to treat [MEDICAL CONDITION] for Resident #7; and (2) addressed medications and dietary interventions related to [MEDICAL TREATMENT] for Resident #9.

Findings include:

1. Resident #7 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The medical record was reviewed on 12/8/16.

Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 10/14/16, indicated that Resident #7 was cognitively intact, required limited assistance from staff for activities of daily living and was taking antidepressant medication. Review of the 12/2016 physician’s orders [REDACTED].

Review of psychotherapy progress note indicated that Resident #7 had difficulty coping with significant losses in his/her life such as the death of a child, giving up his/her home in the community and progression of [MEDICAL CONDITION]. The clinician noted that Resident #7 exhibited episodic mood and behavioral issues which manifested itself in conflicts with his/her roommate, crying and feelings of hopelessness. Interventions identified by the clinician were education related to symptom management and development of coping strategies. Review of the care plan for psychosocial wellbeing and [MEDICAL CONDITION] drug use (last reviewed on 10/19/16) failed to identify targeted behaviors and failed to integrate the psychotherapist’s interventions and goals in the treatment of [REDACTED]. During interview with Unit Manager #3 (UM #3) on 12/8/16 at 10:50 A.M., she said that the psychiatric consultants meet with social services prior to meeting with Residents and not nursing staff.

The Director of Social Services (DSS) was interviewed on 12/8/16 at 12:20 P.M. She said that the psychiatric clinicians usually touch base with social work before meeting with Residents. The DSS was unable to identify specific interventions and goals developed by the psychotherapist to address Resident #7’s symptoms/behaviors related to his/her [DIAGNOSES REDACTED].

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and Resident interviews, the facility failed to ensure that services provided to 2 Residents (#9 and 15), of a total sample of 25 Residents.

Findings include:

Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

2. For Resident #15, the facility failed to ensure that medications were not left at the bedside. Resident #15 was admitted to the facility in 5/2010 and had [DIAGNOSES REDACTED]. The medical record was reviewed on 12/7/16. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/18/16, indicated that Resident #15 was cognitively intact, required extensive assistance of staff with all activities of daily living and was receiving anticoagulant therapy. Review of the 12/2016 physician’s orders [REDACTED].#15’s Peripherally Inserted Central Catheter (PICC) line was to be flushed with 10 milliliters (ml) of normal saline followed by 5 ml of [MEDICATION NAME] after medication administration. During interview with Resident #15 on 12/7/16 at 8:40 A.M., the Surveyor observed two capped syringes (normal saline and [MEDICATION NAME] lock flush 50 USP per 5 ml) on his/her bedside table. Resident #15 told the Surveyor that the nurse injects the medications into the IV (intravenous) tubing to prevent it from getting clogged. The Surveyor asked if he/she administers the medications and he/she said No. During interview with Unit Manager #3 on 12/7/16 at 11:05 A.M., she said that the medication nurse should not have left these medications at his/her bedside.

2. For Resident #9, the facility failed to reconcile medications after the Resident had a hospitalization . Resident #9 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. The Resident was hospitalized in 11/2016 for revision of his/her arteriovenous fistula (AV fistula). The discharge summary, dated 11/1/16 included a summary of the hospital stay and included a list of medications. Review of the hospital discharge record revealed that the medications listed on the discharge summary were not reconciled with the medications listed on the 11/2016 physician’s orders [REDACTED]. The hospital discharge record included the following medications:

[REDACTED] – [MEDICATION NAME] (a [MEDICATION NAME]) 90 mcg, inhale 2 puffs every 6 hours as needed.
– lac-hydrin lotion (topical used for skin issues) apply to feet and legs daily. – Vitamin C 500 mg daily.
– [MEDICATION NAME] (cough medicine) 100 mg daily.
– Sarna (topical anti-itch cream) to both legs twice daily.
– [MEDICATION NAME] (a man-made protein) 1 ml weekly.
– [MEDICATION NAME] cream, apply to feet daily.
– [MEDICATION NAME]3 units three times per day.
– [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 1000 mg twice daily.
– Senna (stool softener) 8.6 mg daily.
– [MEDICATION NAME] (antacid) 40 mg daily.

Review of the MAR for 11/2016 indicated that these medications listed on the discharge summary did not appear on the 11/2016 MAR. The MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. During interview on 12/9/16 at 8:30 A.M., Unit Manager #2 (UM #2) said that she had not reconciled or reviewed the hospital medication list for discrepancies because the Resident had only been at the hospital for 1 day. The Physician was interviewed on 12/9/16 at 9:30 A.M. and said that the nurse should have reviewed the medications with him even if the Resident had been at the hospital for only one day.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to consistently implement the medical plan of care for 2 Residents (#7 and 12) in a total sample of 25 residents.

Findings include:

1. For Resident #12, the facility failed to implement the medical plan of care by applying a right arm sling and elevating the right arm on a pillow while in bed as ordered by the physician. Resident #12 was admitted in 10/2016 and had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set assessment dated [DATE], indicated the Resident had significant cognitive deficits and was dependent in all aspects of his/her activities of daily living.

Review of the medical record on 12/6/16 indicated a physician order [REDACTED]. Further record review indicated that staff had included the order into the written plan of care, dated 10/13/16, and entered it onto the treatment administration records (TAR). The Facility staff documented the arm sling was applied, as ordered and the arm elevated, as ordered. However, the Surveyor observed Resident #12 on 12/6/16 at 2:00 P.M. out of bed without the arm sling. When the Resident was observed in bed on 12/7/16 at 12:50 P.M. the arm was not elevated on a pillow. The Resident was observed on 12/7/16 at 2:00 P.M. and again on 12/8/16 at 9:30 A.M. in bed without either the arm sling when out of bed or the right arm elevated when in bed. For all three days, there was no pillow observed that the arm could rest on and the sling was not in place. On 12/6/16 at 10:30 A.M. and 12/8/16 at 9:30 A.M., Unit Manager #3 was interviewed. She said she was not sure about the arm being raised and that she thought the sling was being washed. On 12/9/16 at 3:40 P.M. the Director of Nursing (DON) was informed of the care issues which resulted in the Resident’s arm not being consistently elevated and positioned in the sling.

2. For Resident #7, the facility failed to ensure that a bed cradle (frame placed over the body of a patient in bed for protecting injured parts from coming into contact with the bed clothes) was in place while the Resident (#7) was in bed. Resident #7 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED].

Review of the significant change and most recent quarterly Minimum Data Set (MDS) with a reference dates of 7/15/16 and 10/14/16 respectively, indicated that Resident #7 was cognitively intact, required limited assistance from staff for activities of daily living and had a history of [REDACTED]. The medical record was reviewed on 12/8/16. Review of the 12/2016 physician’s orders [REDACTED]. The Surveyor made the following observations of Resident #7 lying in bed with no bed cradle in place and bed clothing in contact with the Resident’s body: -On 12/6/16 at 8:45 A.M. and on 12/8/16 at 9:00 A.M., 10:00 A.M. and 3:00 P.M. During interview with Unit Manager #3 on 12/8/16 at approximately 3:00 P.M., the Surveyor alerted her to the above noted observations. She said that staff does not always set up the bed cradle for Resident #7 as ordered by the physician.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure they provided an environment free from accident hazards.

Findings include:

During the initial facility tour on 12/16/16 at 8:05 A.M., Surveyor #1 toured the Baywood Unit (described by facility staff as a long term care unit, with many residents that had impaired cognition). During the tour potential accidental hazards were observed and include the following:

1. Surveyor #1 observed various materials (non-food items and over the counter and prescription medication) in Resident rooms that without proper supervisor, posed a hazard to the Resident population. For example: Multiple resident rooms on 3 of 4 resident units contained medications, as well as razors and scissors accessible on residents’ bureaus and bedside tables. For example: 1. Observation of the Baywood Unit on 12/6/16 at 2:30 P.M. revealed resident room 231 had scissors and razors accessible on the bedside table.

2. Observations of the Baywood and Cedarwood units, Surveyors observed several rooms that had over the counter and prescription medications (vitamins, nasal spray, normal saline, Salonpas (topical pain patches)and heparin syringes that were not secured. For example: a) Non sampled Resident #1 (NS #1), (on 12/6/16 at 8:05 A.M.) the Surveyor observed a bottle of over the counter vitamins (Centrum) on the tray table. Interview with Unit Manager #2 (UM #2) said that the Resident’s family often brought the Resident in different vitamins despite instructions not to do so.

b) For Resident #13, during the initial tour 12/6/16, the Surveyor observed three prescription medications on the bedside table. The medications included Flonase (corticosteroid that is used to treat nasal disorders), ProAir HFA albuterol sulfate (opens airway in the lungs) and saline mist (treats dry and irritated nasal passages). Observation of Resident #13’s room on 12/7/16 at 2:00 P.M. and on 12/9/16 at 11:00 A.M., included 3 medications on the bedside table. Although Resident’s #13 medical record included physician orders [REDACTED].M., and the ProAir 90 mcg, 2 puffs, every 4 hours as needed, there was no order for the saline mist 0.65%, 1 spray each nostril, every hour, as needed.

c) For Resident #14, on 12/6/16 at 8:00 A.M., Ben-Gay (analgesic heat rub), Vicks vapor rub (counter topical decongestant) and a bottle of nasal spray was observed (together) on the Resident’s tray table. The UM #2 confirmed that the Resident did not have an order for [REDACTED].

d) For Resident #15 on 12/7/16 at 8:40 A.M., the Surveyor observed two capped syringes (normal saline and Heparin lock flush 50 USP per 5 ml) on his/her bedside table. Resident #15 told the Surveyor that the nurse injects the medications into the IV (intravenous) tubing.The Resident said that he/she does not self administers the medications. If improperly ingested or handled these products could be potentially hazardous. In addition, resident rooms had containers of bleach wipes/sanitizer in the rooms.

3. Treatment carts on 2 of 4 units were found unlocked and unattended in the unit corridor that were not locked and secured. For example: -Observation of the Cedarwood Unit on 12/6/16 at 10:30 A.M. and 2:30 P.M., found the treatment cart unlocked for more than 20 minutes without staff in the area of the cart. Carts were found unlocked again on 12/7/16 at 2:15 P.M. The Surveyor notified Unit Manager #3 of the unlocked treatment cart.

-On 12/8/16 from 9:55 A.M. until 10:20 A.M. on the Baywood Unit, the treatment cart was unlocked, unsecured and not monitored by the facility staff. On top of the cart was the container the facility used to test blood sugars. There was no cover to the container and there was lancets used to prick the skin that were accessible. During interview on 12/7/16 at 2:30 P.M., the Corporate Clinician were informed of the concern with medications and sharp items and other hazards. The Corporate Clinician said she would sweep the facility for other hazards. During additional general observations following the meeting with the Corporate Clinician on 12/7/16, items reported to the Facility’s administration continued to be accessible including medications, razors and scissors.

Failed to properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and the record review for 1 (#15) of 3 Residents who had Peripherally Inserted Central Catheters (PICC’s) from a total sample of 25 residents, the facility failed to ensure that the line was safe to use after a discrepancy in external length measurements.

Findings include:

Resident #15 was admitted to the facility in 5/2010 and had [DIAGNOSES REDACTED]. The medical record was reviewed on 12/7/16. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/18/16, indicated that Resident #15 was cognitively intact, required extensive assistance of staff with all activities of daily living and was receiving intravenous antibiotic therapy. Review of current physician’s orders indicated that Resident #15’s antibiotic medications included Meropenam and [MEDICATION NAME] (initiated 8/16/16), via a PICC line. The physician’s order also indicated that nursing measure the external catheter length with each weekly dressing change and notify the physician/nurse practitioner if the external catheter length differs from baseline measurement of 3 cm. Review of the facility policy for the care of central catheters indicated that the external length of the catheter was to be measured weekly during the weekly dressing change to assess for migration. Review of the 10/2016, 11/2016 and 12/2016 Medication Administration Records (MAR), indicated that the external catheter lengths, as measured by the nurse was as follows:

0 cm on 10/4/16
0 cm on 10/11/16
1.5 cm on 10/1/16
2 cm on 10/25/16
2 cm on 11/1/16
2 cm on 11/15/16
2 cm on 11/22/16
2 cm on 12/6/16

All measurements taken during the months of October, November and December 2016 were different from the baseline measurement of 3 cm. Despite the discrepancy, facility nurses continued to use the line for administration of intravenous antibiotics.

Per the Infusion Nurses Society’s Infusion Nursing Standards of Practice 2016, infusion through a migrated (malpositioned) catheter should be withheld until proper tip position has been established. The nurse should notify the physician or appropriate delegate immediately of any signs or symptoms related to central venous access device malposition and obtain orders for diagnostic procedures. Procedures include, but are not limited to, chest radiograph and contrast injection through the catheter under fluoroscopy. Unit Manager #3 was interviewed on 12/7/16 at 11:05 A.M. Unit Manager #3 said that no staff person reported the change to the attending physician to determine if the PICC remained safe to use.

Failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

Based on observation, interviews with residents and staff, the resident group meeting, and for 2 of 3 test trays, the facility failed to ensure meals served were palatable and at appropriate temperatures.

Findings include:

During interviews at the time of survey visit 12/6/16 to 12/9/16, 3 of 5 individual residents said that hot foods and hot beverages served at meal times often arrived cold. For example:

1. In the Main Dining Room on 12/6/16 at 5:30 P.M., three residents seated at one table were asked how their soup tasted while they were waiting for their entree to be served and the residents said that the soup was not served hot enough.

2. At the meeting with the resident council group, held on 12/7/16 at 2:00 P.M., residents said food temperatures and accuracy of menu items ordered were still a problem.

3. On 12/7/16, the resident council minutes for the previous three months of meetings were reviewed. The minutes indicated that residents had reported on 9/28/16 that foods at dinner and hot cereal at breakfast were served cold.

4. During the 12/7/16 noon meal observation, the food cart was delivered to the Cedarwood resident unit at approximately 12:04 P.M. A test tray was sampled at the time the last resident tray was served from the Cedarwood unit food cart at 12:20 P.M. and included the following temperatures: the milk registered 56-58 degrees Fahrenheit (F) and tasted warm; the chowder registered 124-126 (F) and tasted tepid, lukewarm; the scalloped potato registered 104-106 (F) and tasted cold; the vegetable squash registered 106-108 (F) and tasted cold.

On 12/8/16 during the noon meal observation on the Baywood resident unit, a test tray was sampled as the last resident was served from the food cart at 12:20 P.M. The food temperatures included the following: the soup registered 118-120 (F); the puree meat registered 119-120 (F); the puree vegetable registered 126 (F); all hot items were tepid, cool to taste.

During interview on 12/9/16 at 2:00 P.M., the Food Service Director (FSD) said that since his arrival at the facility just a month ago, there has been food service positive staffing changes, and going forward the food service is working on additional areas of improvements such as sanitation, tray accuracy, and meal acceptance. Although food service staff routinely recorded food temperatures prior to service on the tray line, the FSD said he did not currently have test tray data of temperatures / satisfaction for the time of service to the residents.

Failed to store, cook, and serve food in a safe and clean way

Based on observations and interviews, the facility failed to maintain a sanitary environment to ensure food safety, reduce presence of pests and ensure that proper food service sanitation practices were followed including the chemical sanitation requirement for the 3 compartment sink (used for pots and pans and wiping cloths) for effective concentration (according to the manufacturer’s specifications) at 200-400 parts per million (ppm) to prevent the development of contamination and potential food borne illness.

Findings include:

During the facility tour of the main kitchen with the Food Service Director (FSD) on 12/06/16 at 9:45 A.M., included the following observations: 1. Food service staff was observed at the three bay sink. The Surveyor asked the FSD for someone to test the chemical concentration of the sanitizer solution for the three compartment sink (where pots & pans are washed, rinsed and sanitized). The food service equipment and wiping cloths are submerged in a solution of sanitizer and water to destroy potential bacterial organisms.

The dietary aide used the (quaternary) test strips stored near the compartment sink. The test strips are designed to change color (color codes according to the manufacturer’s specifications included 200-400 parts per million) based on the concentration of the sanitizer when dipped into the sanitizing rinse water. The diet aide checked the sanitizer solution by placing the test strip into the bucket with solution, however the test strip failed to change color. The diet aide repeated the test and the test strip failed to change color again to indicate the presence of sanitizer. The diet aide manually mixed the sanitizer solution by pouring the (quaternary) chemical sanitizer agent into the bucket with water and then proceeded to use a new test strip. This time the test strip registered an extremely dark color (greater than 400 ppm) above the manufacturer’s recommended concentration. The FSD said that the automated system was not working and the service provider would be called to repair or replace the unit. Although review of the sanitizer log documentation sheet on 12/6/16 indicated that the sanitizer sink /solution was checked daily 12/1/16 to 12/6/16, recorded at 200 ppm concentration, the facility failed to implement measures that the sanitizer solution be checked for proper concentration each time a sink or bucket of solution was manually prepared to ensure effective concentration (200-400 ppm) to destroy potential organisms and prevent contamination and potential food borne illness.

2. Improper food storage was observed in the walk-in freezer as containers (pans) of cauliflower was stored on the floor of the freezer. The freezer unit was not maintained in sanitary manner as food spillage and particles of debris was seen on the flooring.

3. Observations of the flooring, including the main kitchen, food storage rooms, walk-in refrigerator and freezer were unclean with evidence of food particle debris, paper trash and old dried spills. The build-up was not the result of the the morning’s breakfast meal production or recent food delivery stock.

4. The plate warming unit was in disrepair, as seams and edges contained black tape, and surfaces that are difficult to clean. The FSD said that the facility would be in pursuit of a new unit.

5. The hand sink in the main kitchen was in disrepair as water leaked from the pipe and dripped onto the floor creating a pool of water under the hand sink.

6. During the survey visit 12/6/16/ to 12/9/16, the food trucks and food carts were observed dirty and not maintained in clean and sanitary condition. A build-up of old food spillage and grime was seen in the crevices and on outside surfaces of the equipment.

7. The wall surface was unclean near the clean equipment storage as it had dried splattered old dried food/beverage the duration of the survey (12/6/16 to 12/9/16).

8. Kitchen equipment exterior surfaces (ovens, steam unit, steam table, plate warmer unit) were in need of cleaning as they had a build up of grease and grime.

9. The nourishment area on the Bayside unit: the microwave was observed with dried food particles and splatters on the interior. The refrigerator did not close properly as the lower drawer unit was not positioned properly and the door gasket was in disrepair and dirty. The interior of the refrigerator was also unclean with food spillage. The FSS was interviewed on 12/6/16 at 10:30 A.M. and said that there has been a lot of changes since his arrival at the facility and that new master cleaning schedule for the staff was established, although there was still areas that they are working on. 10. In all food service areas, black small flying insects were observed throughout the facility during the survey visit 12/6/16 to 12/9/16. Observations included the following:

-The flying insects were seen in the nourishment area on 12/6/16 at 9:10 A.M. on the Baywood unit.
– The flying insects were seen in the main kitchen on 12/6/16 during the evening meal service at 4:58 P.M. near the three bay sink, and at 5:10 P.M. in the dish room area.
-The flying insects were present in the main dining room on 12/6/16 at 5:30 P.M. during the supper meal.
– The flying insects were seen on the Cedarwood unit on 12/7/16 at 12:10 P.M.
-The flying insect was observed on the Baywood dining room on 12/8/16 at 12:15 P.M.
-The insects were observed on 12/9/16 at 8:30 A.M., flying on and off residents’ uneaten foods in the main dining room upon completion of the breakfast service.
-The flying insects were seen on the Driftwood unit on 12/9/16 at 10:10 A.M. During interview with the Plant Operations Manager and FSD, on 12/7/16 and 12/8/16, The plant manager said that the facility has had the drains in the food service area treated once, from contracted service for the pest (black drain fly) problem; and the grease trap unit was also cleaned routinely.

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Sources:

Medicare Nursing Home Profiles and Reports – Baypointe Physical Rehabilitation Center

Inspection Report for Baypointe Physical Rehabilitation Center – 12/09/2016

Page Last Updated: June 9, 2018