Beaumont Rehab & Skilled Nursing Ctr - Westboro

Inspectors wroteBased on interview and record review, the facility failed to ensure that two Residents (#11 and #6), out of a total sample of 30 residents, were free from significant medication errors. Specifically, the staff failed to: 1. For Resident #11, ensure that Seroquel (a medication used to help regulate mood, behaviors and thoughts) was accurately transcribed onto the Medication Administration Record (MAR), resulting in the Resident missing 19 doses of the prescribed medication, and increasing the risk for worsening mood and behavior patterns. 2. For Resident #6, ensure Metoprolol Tartrate (medication used to treat high blood pressure) and Midodrine (medication used to treat low blood pressure) were administered to the Resident in accordance with physician ordered parameters, increasing the Resident's risk for adverse medication reactions.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide food at safe and appetizing temperatures to residents from two out of three lunch meal carts on two Units ([NAME] Unit and [NAME] Unit) out of three total resident units. Specifically, the facility failed to provide food at safe and appetizing temperatures for the lunch meal for Residents eating lunch on the [NAME] Unit and [NAME] Unit, increasing residents' risks for reduced food/fluid intake.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to make prompt efforts to adequately resolve grievances for two Residents (#82 and #7) out of a total sample of 30 residents. Specifically, the facility failed to:1. For Resident #82, -identify steps taken to investigate the Resident's grievance with respect to care not being provided.-summarize pertinent findings or conclusions regarding the Resident's concern with respect to care not being provided.-state whether the Resident's grievance with respect to care not being provided was confirmed or not confirmed.2. For Resident #7, the facility failed to adequately resolve the Resident's grievance for missing dentures in a timely manner when the Resident's lower dentures were missing.

Inspectors wroteBased on interviews, and record review, the facility failed to implement the person-centered care plan relative to transfers for one Resident (#70) out of a total sample of 30 residents. Specifically, for Resident #70, the facility failed to ensure that two staff assists were utilized per his/her plan of care when transferring the Resident with the use of a mechanical lift, putting the Resident at risk for injury or falls.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that three Residents (#3, #11, and #15), out of a total sample of 30 residents was provided the right to participate in their care plan process. Specifically, for Residents (#3, #11, and #15), the facility failed to ensure that each Resident was invited to participate in their individual care plan meeting process and the facility also failed to provide rationale as to why the participation of the three Residents was determined not practicable for the development of the care plan.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide treatment and services related to an indwelling urinary catheter (thin, flexible tube inserted into the bladder to drain urine outside the body) for two Residents (#93 and #51), out of a total sample of 30 residents. Specifically, the facility failed:1. For Resident #93, to implement the physician's orders relative to the correct indwelling urinary catheter size as ordered by the Physician, increasing the Resident's risk for indwelling urinary catheter complications.2. For Resident #51, to ensure that the urinary catheter drainage bag was not placed directly on the floor, placing the Resident at risk for contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#93), out of a total sample of 30 residents. Specifically, for Resident #93, the facility failed to ensure that Enhanced Barrier Precautions (EBPs - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), were appropriately utilized when providing high contact care for the Resident, to mitigate the risk of organism transmission and the spread of infection to the Resident and other residents within the facility.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required set up assistance with meals and beverages, the Facility failed to ensure his/her environment was free from accidents resulting in serious injury, when on 1/16/26, a staff member served Resident #1 a hot cup of coffee that had been reheated in the microwave, however the staff member did not check the temperature of the coffee, in accordance with facility policy, before serving it to him/her. The hot coffee was spilled onto Resident #1, and he/she sustained second degree burns (partial thickness, involves both the first and second layer of skin and appears red, blistered, and maybe swollen or painful) to his/her bilateral upper thighs, which required daily treatment and monitoring by nursing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a device utilized for one Resident (#38), was assessed when used as a physical restraint, for one applicable Resident who had nephrostomy tubes (tubes that drain urine from the kidneys into drainage bags), out of a total sample of 27 residents. Specifically, the facility failed to assess Resident #38 for the need of an abdominal binder (wide compression belt that encircles the abdomen) to cover Resident #38's nephrostomy sites to prevent him/her from pulling on the nephrostomy tubes.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#36), out of a total sample of 27 residents. Specifically, for Resident #36, the facility staff failed to request a Level II PASARR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#36), out of a total sample of 27 residents. Specifically, for Resident #36, the facility failed to complete an assessment and ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observation and interview, the facility failed to accurately and safely provide pharmaceutical services pertaining to the administration of routine medications for one Resident (#40), out of a total of five resident medication administration observations. Specifically, the facility failed to ensure that Resident #40's Furosemide (medication used to treat high blood pressure, heart failure and build-up of fluid in the body) medication: -was dispensed from the pharmacy. -was administered in the correct dose to the Resident when the facility staff used a higher dose medication tablet and broke the higher dose tablet to obtain the ordered dose.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted within the required timeframe after the completion date for one Resident (#46), out of one applicable resident, out of a total sample of 27 residents. Specifically, for Resident #46, a discharge MDS assessment was not transmitted within 14 days of the MDS assessment completion date as required.

Inspectors wroteBased on observation, policy and record review and interview, the facility failed to adhere to infection control guidelines to prevent contamination and the spread of infection. Specifically, the facility staff failed to: 1.a) don (put on) gloves when handling medications. b) ensure a medical supply bag was placed in a clean area. c) ensure handwashing occurred after doffing (remove) gloves. d) ensure proper COVID-19 (an infectious respiratory illness) staff testing procedure. 2. to perform COVID-19 testing for staff and residents in a manner consistent with infection control standards and perform COVID-19 testing for staff timely as required.

Inspectors wroteBased on record review and interview the facility failed to notify the Physician when medications were not administered for one Resident (#283) out of a total sample of 30 residents. Specifically, the facility staff failed to notify the Physician when medications were not administered as ordered upon the Resident's admission to the facility, and prior to Renal Dialysis treatments.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure professional standards of quality were maintained during observation of a medication pass for one Resident (#45), out of eight applicable residents, in a total sample of 30 residents. Specifically, -for Resident #45, the facility staff failed to follow professional standards related to crushing enteric coated (EC-special coating that prevent dissolving by stomach acids but allows release of the medication in the intestine) medications prior to administration.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide treatment, care, and services as required for one Resident's (#77), out of a total sample of 30 residents. Specifically, the facility staff failed to respond timely to Resident #77's request to use the bathroom, when the Resident required assistance from staff with activities of daily living (ADLs).

Inspectors wroteBased on observations, record review, and interview the facility failed to assess, provide, and implement activities of the Resident's choice for one Resident (# 77) out of a total sample of 30 residents. Specifically, the facility staff failed to assess Resident #77 for activities preferences, provide meaningful activities designed to meet his/her interests and support his/her physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide Behavioral Health Services for one Resident (#91) out of a total sample of 30 residents. Specifically, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for a resident identified with a history of suicidal ideation, and a documented suicide attempt while in the facility resulting in hospitalization. Findings Include: Review of the Facility Policy titled Behavior Management Program, last revised 11/1/2010, indicated the following: -Resident's with behaviors that are problematic and/or dangerous for themselves or others will be identified. -Staff should look for triggers of previous circumstances that lead up to the problematic behavior. [...]

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement a Consultant Pharmacist recommendation for one Resident (#86) out of 5 residents reviewed, out of a total sample of 30 residents. Specifically, the facility staff failed to implement a Consultant Pharmacist recommendation, agreed upon by the attending Physician for uric acid serum levels to monitor the results of medication therapy for Resident #86.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a significant medication error did not occur for one Resident (#37), out of a total sample of 30 residents. Specifically, the facility failed to ensure Paxlovid (an oral antiviral pill) used to treat Covid-19 (an infectious respiratory illness) was available for administration.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the appropriate storage and safety of medications per professional standards. Specifically, the facility staff failed to ensure: 1. drugs and biologicals were ordered and safely stored for one out of two Medication Storage Rooms. 2. medication was safely stored for one Resident (#86), out of a total sample of 30 residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain complete, accurate, and readily accessible medical records for three Residents (#39, #122, and #37), out of a total sample of 30 residents. Specifically, the facility staff failed to: 1. ensure for Resident #39, accurate and complete documentation of the interdisciplinary care plan meetings. 2. ensure for Resident #122, an accurate Physician medication order for Paxlovid ([an oral antiviral pill] used to treat Covid-19 [an infectious respiratory illness]) was prescribed. 3. ensure for Resident #37, a Physician order for Paxlovid was transcribed correctly in the Medication Administration Record (MAR).

Inspectors wroteBased on record review and interview, the facility failed to ensure that two Comprehensive Minimum Data Set (MDS) Assessments were completed timely as required for one Resident (#25) out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview the facility failed to transmit a significant change Minimum Data Set (MDS) Assessment timely as required for one Resident (#25) out of a total sample of 30 residents.