Inspection Reports for Baywind Village Skilled Nursing & Rehabilitation
TX, 77573
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan development and revision requirements, and to evaluate the provision of appropriate colostomy care for residents.
Findings
The facility failed to ensure that the comprehensive care plan for Resident #64 was reviewed and revised by an interdisciplinary team to reflect catheter discontinuation. Additionally, the facility failed to provide consistent colostomy care, training, and documentation for Residents #76 and #293, resulting in risks of complications and emotional distress.
Deficiencies (2)
Failure to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team for Resident #64 to reflect catheter discontinuation.
Failure to provide appropriate colostomy care consistent with professional standards for Residents #76 and #293, including inconsistent documentation, improper classification of colostomy, and failure to empty colostomy bags regularly.
Report Facts
Residents reviewed for care plan: 18
Residents reviewed for colostomy care: 4
Residents affected by care plan deficiency: 1
Residents affected by colostomy care deficiency: 2
Medication refusal instances: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator A | Interviewed regarding care plan revision responsibility and oversight for Resident #64 | |
| DON | Director of Nursing | Interviewed regarding care plan revision requirements and colostomy care practices |
| RN G | Registered Nurse | Provided information on colostomy care practices and assessments for Resident #293 |
| LVN C | Licensed Vocational Nurse | Discussed colostomy care frequency and documentation for Resident #76 |
| RN I | Registered Nurse | Provided colostomy care and training for Resident #76 and Resident #293 |
| CNA D | Certified Nursing Assistant | Described colostomy monitoring and documentation practices |
| CNA E | Certified Nursing Assistant | Reported colostomy bag fullness and communication with nursing staff |
| MD A | Medical Doctor | Discussed colostomy care training and complications |
| ADON | Assistant Director of Nursing | Discussed colostomy care training and resident concerns |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident (CR#1) by a CNA on 04/24/24.
Complaint Details
The complaint was substantiated as the facility confirmed physical abuse of resident CR#1 by CNA A on 04/24/24. The responsible party was notified, police were involved, and the employee was terminated. The District Attorney dismissed the case due to lack of evidence.
Findings
The facility failed to ensure that CR#1 was free from abuse when CNA A physically abused the resident and threatened her roommate. The abuse incident was confirmed, the perpetrator was terminated, and corrective actions including staff in-service and notifications to authorities were completed prior to the survey.
Deficiencies (1)
Failure to protect resident CR#1 from physical abuse by CNA A on 04/24/24.
Report Facts
Residents affected: 1
Residents reviewed for abuse: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named as the perpetrator of physical abuse against resident CR#1. |
| Director of Nursing | DON | Interviewed regarding the abuse incident and facility response. |
| Assistant Administrator | Interviewed regarding facility actions following the abuse incident. | |
| Administrator | Interviewed regarding facility actions following the abuse incident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify resident representatives of significant changes in condition and inadequate preparation for resident discharge.
Complaint Details
The complaint investigation revealed that the facility failed to notify the responsible party of resident #1's hypotensive event and seizure, resulting in delayed family awareness and subsequent adverse outcomes. Additionally, the facility failed to ensure resident #2 was discharged with home health services in place, causing a disruption in care and family dissatisfaction.
Findings
The facility failed to notify the responsible party of a resident's significant change in condition after a hypotensive event and seizure, and failed to ensure a resident was discharged with home health services in place, risking disruption in care.
Deficiencies (2)
Failure to notify resident representative of significant change in condition for 1 of 5 residents reviewed.
Failure to provide and document adequate preparation for safe and orderly transfer or discharge for 1 of 3 residents reviewed.
Report Facts
Residents reviewed for resident rights: 5
Residents reviewed for transfer/discharge: 3
Blood transfusions given: 11
Date of care plan revision: Apr 29, 2024
Date of discharge: Apr 25, 2024
Date home health services started: May 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to notify family of resident #1's condition and hypotensive event |
| Administrator | Interviewed regarding notification failure for resident #1 | |
| DON | Director of Nursing | Interviewed regarding notification expectations and counseling of RN A |
| ADON | Assistant Director of Nursing | Interviewed regarding change in condition notification procedures |
| Discharge Planner | Named in failure to ensure home health services in place for resident #2 discharge | |
| Discharge Planner Assistant | Named in discharge planning and communication with family for resident #2 | |
| Assistant Administrator | Interviewed regarding discharge planning failures |
Inspection Report
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with resident rights, specifically regarding informed consent for treatment and medication administration.
Findings
The facility failed to ensure that one resident (CR #1) was fully informed and gave consent prior to administration of the antidepressant medication Zoloft. The resident did not sign consent for the medication, and the facility's policy did not address antidepressant medication consent. This posed a risk of residents receiving medications without prior knowledge or consent.
Deficiencies (1)
Failure to ensure residents are fully informed and understand their health status, care, and treatments, specifically failure to obtain informed consent for antidepressant medication.
Report Facts
Residents reviewed for rights: 18
Resident involved: 1
Medication dosage: 25
Medication administration days: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated CR #1 was his own responsible party and requested antidepressant medication; noted no signed consent in clinical record | |
| Psychiatric Nurse Practitioner | Prescribed antidepressant medication; stated normally explains side effects and prescribes after evaluation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
The inspection was conducted as a routine annual survey of Baywind Village Skilled Nursing & Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 4, 2023
Visit Reason
The inspection was conducted to assess compliance with resident dignity and infection prevention and control standards at Baywind Village Skilled Nursing & Rehab.
Findings
The facility failed to provide privacy for Resident #1 during a wound dressing change due to the absence of a privacy curtain, and failed to maintain proper infection control practices during the dressing change, placing the resident at risk for embarrassment, lower self-esteem, cross contamination, and infection.
Deficiencies (2)
Failure to have a privacy curtain in Resident #1's room during wound dressing change, compromising dignity and respect.
Failure to practice proper infection control during Resident #1's dressing change, including inadequate hand hygiene and workspace sanitization.
Report Facts
Residents affected: 1
Residents observed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in findings related to failure to provide privacy and improper infection control during dressing change |
| CNA B | Certified Nursing Assistant | Assisted LVN A during dressing change |
| Administrator | Interviewed regarding missing privacy curtain | |
| Maintenance Director | Interviewed regarding missing privacy curtain |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 13, 2023
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements including pharmaceutical services, food safety, garbage disposal, medical record maintenance, and infection prevention.
Findings
The facility was found deficient in pharmaceutical services for failing to ensure Resident #127 received and was administered Retacrit medication as ordered, food safety due to expired food found in the refrigerator, improper garbage disposal with unsecured dumpster lids, incomplete and inaccurate clinical documentation for Resident #127, and inadequate infection prevention practices with staff failing to perform hand hygiene between resident feedings.
Deficiencies (5)
Failure to provide pharmaceutical services ensuring Resident #127's Retacrit injection was received and administered per physician order.
Expired food (turkey wrap) found in refrigerator beyond use-by date.
Dumpster lids and doors were not secured, risking pest infestation.
Resident #127's progress notes were incomplete and inaccurate regarding medication administration.
Staff failed to perform hand hygiene between assisting multiple residents with feeding.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Hemoglobin lab value: 11.1
Use-by date: Jan 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Interviewed regarding Resident #127's medication administration and documentation |
| DON | Director of Nursing | Interviewed regarding medication orders, documentation, and infection control |
| Dietary Aid A | Dietary Aide | Interviewed regarding expired food and dumpster lid observations |
| Dietitian/Dietary Manager | Dietitian/Dietary Manager | Interviewed regarding expired food and dumpster lid observations |
| CNA-A | Certified Nursing Assistant | Observed and interviewed regarding failure to perform hand hygiene between resident feedings |
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