Beatitudes Campus

Inspectors wroteBased on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations and policy review, the facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'.

Inspectors wroteBased on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations, and policy review, the facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'.

Inspectors wroteBased on interviews, review of clinical record, and facility records, policy, and procedures, the facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member. The deficient practice could result in psychosocial harm.-

Inspectors wroteBased on interviews, review of clinical record, and facility policy, the facility failed to ensure a thorough investigation was conducted and recorded, and that a resident (#66) was assessed for injury regarding an allegation of abuse. The deficient practice could lead to continued physical and psychosocial harm of a resident, and/or a missed injury and delay of care.-

Inspectors wroteThe facility failed to ensure resident assessments for two residents were encoded and transmitted according to regulatory requirements. The deficient practice can impact the facility's ability to monitor changes to residents' health data over time. Based on clinical record review, interviews, facility policy and procedure, the facility failed to ensure Minimum Data Sets (MDS) for two residents (#3 and #12) were encoded and transmitted according to regulatory requirements. The deficient practice can impact the facility's ability to monitor changes to residents' health data over time. Findings Include:-Regarding Resident #3Resident #3 was admitted to the facility on [DATE] with diagnoses that included unspecified injury of the head, and difficulty walking. [...]

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#34) was reported to the State Agency.

Inspectors wroteBased on clinical record review, staff interview, and policies and procedures, the facility failed to ensure that a comprehensive person-centered care plan with interventions related to use of oxygen was developed for one resident (#38) and related to the use of a power wheelchair seatbelt and bed rails/mobility bars for one resident (#44). The deficient practice could result in the resident not receiving the necessary care and services according to their assessed needs.

Inspectors wroteBased on clinical record review, observations, interviews, and policy review; the facility failed to ensure oxygen was administered as ordered for one resident (#38); and, failed to ensure there was a physician order for the use of oxygen for one resident (#50). The deficient practice could result in resident complication and respiratory distress and hospitalization.

Inspectors wrote-Regarding Foley catheter bag An observation was conducted on August 28, 2024 at 7:51 AM. The resident (#19) was lying in bed with his indwelling catheter bag laying on the floor beside the resident's bed. Another observation was conducted on August 28, at 11:07 AM and revealed the resident (#19) was in bed with the indwelling catheter bag on the floor beside the resident's bed. In an interview on August 28, 2024, at 11:37 AM, a certified nursing assistant (CNA/staff #11) stated that the catheter bag should not be on the floor in order to stay clean. An interview with another CNA (staff #1) was conducted on August 28, 2024, at 11:42 AM. The CNA (staff #1) stated that the catheter bag should not be on the floor, and if it is on the floor, then there is a risk of infection. An observation of resident #19 was conducted with the CNA (staff #1) during the interview; [...]

Inspectors wroteBased on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents. The deficient practice could result resident not having a homelike environment and risk for injury and harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to maintain an effective training program for two of 15 sampled staff (#70 and #19). The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received ongoing education on residents rights . The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received training on abuse, neglect and exploitation. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received training on infection control. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm.

Inspectors wroteBased on clinical record review, interviews, facility documentation and a policy review, the facility failed to ensure that one sampled resident (#37) was notified prior to the room change. The deficient practice could result in residents and their representatives, not provided with the opportunity to exercise autonomy regarding their interests, preferences and desires, in regards to a room change.

Inspectors wroteBased on observation, record review, interviews, and facility policy review the facility failed to ensure one resident (#44) was assessed and care planned for the use of a power wheelchair seatbelt and bed rails/mobility bars. The deficient practice could lead to a resident experiencing decreased mobility, possible entrapment, and psychosocial and/or physical harm.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure daily staff posting was current and posted at the beginning of each shift. The deficient practice could result in the accurate daily staffing information not available to residents and visitors.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure that the third-floor resident nourishment refrigerator food was stored in accordance with professional standards for food service safety. The deficient practice could result in food growing harmful bacteria that is a risk factor to cause foodborne illness.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#18) or resident representative was informed in advance of the risks and benefits prior to administration of a psychotropic medication. The deficient practice could result in not having the right to choose the option the resident prefers.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure care provided met professional standards of care by failing to follow physician orders regarding insulin for one resident (#14). The deficient practice could result in adverse outcomes and/or complications related to diabetes mellitus (DM).

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy, the facility failed to ensure an allegation of abuse for one resident (#39) was reported as required. The deficient practice could lead to continued abuse of the resident or other residents.

Inspectors wroteBased on clinical record review, review of facility documentation, staff interviews and review of facility policy, the facility failed to prevent further potential abuse by staff following an abuse allegation for one resident (#39). The deficient practice could lead to continued abuse of the resident or other residents.

Inspectors wroteBased on clinical record, staff interview and facility policy and procedures, the facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level 1 screening was completed as required for one resident (#25). The deficient practice could result in specialized services not provided to meet resident's needs.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to use the services of a Registered Nurse (RN) for at least eight hours consecutive hours a day, seven days a week. The census was 57 and the sample was 15. The deficient practice could result in not enough staff to meet the resident's needs.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to ensure he Daily Staff Postings for nursing staff were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Inspectors wroteBased on observation, staff interview and review of facility policy, the facility failed to ensure food items were stored in accordance with professional standards for food service safety by failing to ensure temperatures for the refrigerators were consistently monitored, maintained and documented. The deficient practice could result in food served to residents not safe for consumption.