Award Care at Beneva

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to prevent avoidable accidents by failing to ensure the appropriate storage of ignition devices for 6 (Residents #71,#106, #9, #26, #43, and #67) of 23 residents who smoke tobacco products and/or use oxygen. The unsafe practice of allowing residents to store ignition sources such as lighters in their rooms where oxygen is in use created a significant fire safety risk to the entire facility. [...]

Inspectors wroteBased on observation, record review, residents and staff interviews, the facility administration failed to provide effective oversight and enforcement of safe smoking practices. The facility Administration became aware of the concerns of unsafe storage of ignition devices and failed to intervene to protect the health and safety of all residents, as evidenced by interviews with the Director of Nursing and the Administrator who both stated that the issues were brought to their attention in September and October of 2025 when they started working in the facility. This failure created an environment that placed all 101 residents who reside in the single-story facility at a likelihood of serious injury, impairment or death from thermal burns and inhalation of toxic fumes and resulted in the determination of Immediate Jeopardy.

Inspectors wroteBased on observation, record review and interviews, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to address the known unsafe smoking practices since September 2025 for 6 (Residents #71, #106, #9, #26, #43, and #67) of 6 sampled residents who smoke tobacco products. The facility failure to develop corrective actions to ensure the safe storage of ignition devices and continuing to allow residents who use oxygen to retain/store lighters in their rooms created a significant, avoidable fire safety risk that could impact all 101 residents who reside in the single-story facility. A fire originating in one resident's room can rapidly spread, produce smoke and fumes that travel rapidly through hallways and ventilation systems, creating a likelihood of serious harm, injury or death. [...]

Inspectors wroteBased on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's supervised smoking policy to ensure safe smoking practices for 6 (#71, #106, #9, #26, #43, and #67) of 6 sampled smokers and prohibit the storage of ignition devices around oxygen use for 2 (Residents #71 and #106) of 2 sampled residents reviewed for safe smoking. The facility failure to enforce the smoking policy that clearly addressed the safe storage of ignition devices by allowing residents who use oxygen, or share rooms with residents who use oxygen, to keep lighters/ignition devices unsecured in their rooms created an avoidable fire safety risk, placing all 101 residents who reside in the single story facility at a likelihood serious harm, injury or death from thermal burns and inhalation of toxic fumes. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to follow physician orders for enteral feeding supplies for 1 of 3 residents sampled, (Resident #41).

Inspectors wroteBased on observation, review of facility policy and staff interviews, the facility failed to provide a clean and sanitary environment for 3 residents, (Resident #82, #41 and #59) of 7 residents sampled.

Inspectors wroteBased on observation, review of facility policy, record review and resident and staff interview, the facility failed to ensure 1, (Resident #89), of 1 resident with a pressure ulcer received treatments, including turning and repositioning using a wedge pillow, as part of pressure ulcer prevention and management.

Inspectors wroteBased on observation, record review and staff and resident interview, the facility failed to administer intravenous (IV) medication as ordered for 1, (Resident #90), of 1 resident sampled with a urinary tract infection (UTI). The failure to administer antibiotics as ordered can lead to treatment failure, prolonged illness and the development of dangerous antibiotic-resistant bacteria.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were offered an opportunity to consent or decline vaccines, received the vaccines consented for, unless medically contraindicated for 1 (Resident # 5) of 5 residents reviewed for vaccines.

Inspectors wroteBased on record review, residents and staff interviews, the facility failed to ensure 2 (Residents #900 and #800) of 3 dependent residents reviewed were treated with dignity by failing to respond timely to residents' call lights and failing to provide incontinent care to meet the residents' needs.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to provide assistance with showers as outlined in the resident's care plan and according to residents' preferences for 2 (Residents #900 and #800) of 3 dependent residents reviewed.

Inspectors wroteBased on observation, record review, staff interview and review of facility policy and procedure the facility failed to implement corrective actions to achieve and maintain compliance in previously cited deficiencies.

Inspectors wroteBased on record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to report an allegation of physical abuse to the Agency for Health Care Administration within the specified timeframe for 1 (Resident #1) of 3 residents reviewed.

Inspectors wroteBased on observation, review of facility's policy and procedure and staff interview, the facility failed to ensure medications were kept locked in 1 (300 hall) of 4 medications carts observed when not in use and under direct supervision.

Inspectors wroteBased on record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to protect residents' rights to be free from neglect by failing to follow physician medication orders for 2 (Resident #875 and #775) of 4 residents reviewed. The facility failed to perform and document weekly skin evaluations for 1 (Resident #99) of 3 sampled residents at risk for pressure ulcer to ensure timely identification and treatment of skin alterations.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to ensure staff consistently performed weekly skin evaluations for 1 (Resident #99) of 3 residents reviewed for early identification and treatment of pressure ulcers.

Inspectors wroteBased on review of facility's policies and procedures, review of the Resident council meeting minutes, and staff interviews, the facility failed to respond to grievances and recommendation voiced by the Resident Council for 5 (May, June, July, September, and October 2023) of 7 months of council minutes reviewed.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a comfortable environment for 1 (Resident #59) of 2 residents sampled for missing property in that they failed to exercise reasonable to minimize the loss of personal property.

Inspectors wroteBased on observation, review of facility policies and procedures, record review, staff and resident interviews, the facility failed to demonstrate effective coordination to ensure 3 (Resident #37, #96 and #399) of 3 resident's reviewed received appropriate medical care and treatment.

Inspectors wroteBased on observation, staff and resident interviews, review of facility policy and procedure, and record review, the facility failed to ensure 3 (Residents #7, #32, and #41) of 24 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails.

Inspectors wroteOn 10/9/23 at 9:28 a.m., in an interview Resident #57 said she was allergic to pork and the kitchen is still sending it. She said she was allergic to Styrofoam and had asked not to receive her meals in Styrofoam but they keep sending it. Resident #57 said, I tell them every day, but they keep sending pork. Today I had bacon with my eggs. Observation of the noon meal on 10/9/23 at 12:52 p.m., Resident #57 received the savory pork roast as indicated on the meal ticket and did not eat any portion of the meal. The resident said I keep telling them I don't eat pork. I told the certified nursing assistant (CNA) when he brought me the lunch tray, I don't eat pork. He said well then, it's chicken and walked out of the room. I know the difference between pork and chicken, I'm not stupid. Review of the lunch meal ticket identified allergies Shellfish allergy, Styrofoam allergy. [...]

Inspectors wroteBased on observation, and staff interview the facility failed to serve food in accordance with professional standards for food service safety. The failure to use beard coverings and perform hand hygiene could lead to cross contamination and cause food borne outbreaks. This had the potential to impact 93 residents consuming food at the community.

Inspectors wroteBased on observation, record review, staff and resident interview, the facility failed to provide the necessary care and services to maintain personal grooming and hygiene for 2 (Residents #32, and #74) of 2 residents reviewed who require assistance with activities of daily living.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review the facility failed to ensure appropriate assessment, documentation, and monitoring after a fall incident for 1 (Resident #25) of 7 resident reviewed for accidents. The facility also failed to ensure safe smoking practices for 1 (Resident #19) of 7 residents reviewed for accident.

Inspectors wroteBased on staff interviews and record review the facility failed to provide care and services consistent with professional standards of practice by failing to ensure ongoing, and accurate assessment upon return from the dialysis center for 1 (Resident #29) of 2 dialysis residents reviewed.

Inspectors wroteBased on staff interviews and staff record reviews, the facility failed to ensure 3 (Staff G, J, and K) of 5 Certified Nursing Assistants records reviewed had a performance review completed at least once every 12 months as required.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen and equipment in a clean, safe, and sanitary manner and in good repair with regards to unclean cooking surfaces, equipment heavily soiled, unclean surfaces near food preparation equipment. These deficient practices had the potential of spreading harmful microorganism, which could cause food borne illness to residents consuming an oral diet.

Inspectors wroteBased on record review and staff interview the facility failed to ensure 1 (Resident #197) of 22 residents reviewed, was informed, and provided written information about advance directives. The failure to provide advance directives information to the resident and/or their representative could lead to them not knowing their rights to make choices concerning health care and treatments for life sustaining measures and to ensure their wishes were honored.

Inspectors wroteBased on record review, and staff and resident interview, the facility failed to obtain dental services in a timely manner for 1 (Resident # 81) of 1 resident identified in need of dental services.