Beautiful Savior Home

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from abuse when on 5/7/26 Resident #2 forceable grabbed the resident's chin/jaw area causing discoloration and bruising out of 3 sampled residents. The facility census was 70 residents. On 5/15/26, the Administrator was notified of past non-compliance which occurred on 5/7/26. Immediate interventions were put in place for both Resident #1 and Resident #2. All staff received education prior to working their next shift. The deficiency was corrected on 5/8/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent physical abuse for one sampled resident (Resident #2) out of five sampled residents. On 4//26/26 Resident #1 struck another Resident #2 in the face with his/her fist causing redness and bruising. The facility census was 72 residents. On 5/6/26, the Administrator was notified of past non-compliance which occurred on 4/26/26. Immediate interventions were put in place for both Resident #1 and Resident #2. All staff received education prior to working their next shift. The deficiency was corrected on 4/27/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager (DM) met one of the qualifications for a Certified Dietary Manager (CDM) by having an approved certification for food service management and safety from a certifying body, an associate's degree in food service management or hospitality, or had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management. This practice potentially affected all residents. The facility census was 76 residents. Review of the facility's Dietitian policy, revised November, 2022 showed if a Dietitian is not employed full time (35 or more hours per week) a Director of Food and Nutrition Services will be designated. This individual will: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure condiments were stored properly, clean grease and food from condiment and spice containers, clean grease build up from kitchen surfaces including the stove and oven, remove build-up of soap or other substances from soap dispensers, a soap dish, and dish washing machine trays, and to ensure trays and food containers were not stored on surfaces that were chipped and therefore unable to be sanitized. This practice potentially affected all residents who ate food from the kitchen. The facility census was 76 residents. 1. Observation on 12/05/24 from 9:31 A.M. to 12:55 P.M. showed: -At 9:31 A.M. bits of debris were all over the kitchen floor, most of which were one-half inch and smaller, with a few bits larger. There were multiple spills on the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control practices for three sampled residents (Resident #58, #27, and #74) who was on Enhanced Barrier Precautions (EBP - refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove during high contact resident care activities) failed to use adequate hand hygiene during incontinence care for (Resident #58); failed to ensure infection control was maintained during wound care for one sampled resident(Resident #2); failed to perform proper hand hygiene during cares for one sampled resident (Resident #74); [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) staff were able to identify who was CPR certified staff on all shifts. The facility census was 76 residents. Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy revised February 2018 showed: -Personnel have completed training on initiation of cardiopulmonary resuscitation and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 76 residents. Review of the facility Antibiotic Stewardship policy, revised December 2023 showed: -Antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. -Instruction that physician's orders for antibiotics would include the drug name, dose, frequency of administration, duration of treatment, start and stop date or number of days of therapy, route of administration and the indications for use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with bathing received baths and/or showers to meet the needs of one sampled resident (Resident #68) out of 18 sampled residents. The facility census was 76 residents. Review of facility policy Bath, Shower/Tub revised 2/2018 showed: -The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. -Document date and time the bath or shower was preformed. -Document the name and title of the individual(s) who assisted the resident with the shower/tub bath. -Document all assessment data (e.g., any reddened areas, sores, etc., on the residents skin) obtained during shower/tub bath. -Document if the resident refused the shower/tub bath, reason(s) why and the interventions taken. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weekly wound tracking for one sampled resident (Resident #2) with a history of a chronic Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); and failed to ensure services to prevent and heal pressure ulcers for one sampled resident (Resident #58) who was at high risk for skin breakdown out of 18 sampled residents. The facility census was 76 residents. Review of the facility Wound Care Policy, revised 10/2010 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough fall investigation to include interviews of staff and/or potential witnesses, failed to complete fall assessments after each fall, and failed to implement appropriate interventions for a significantly cognitively impaired resident (Resident #32) out of 18 sampled residents. The facility census was 76 residents. Review of the facility policy Assessing Falls and Their Causes Revised 3/2018 showed: -When a resident falls, the following information should be recorded in the resident's medical record: --The condition of which the resident was found. --Assessment data, including vital signs and any obvious injuries. --Interventions, first aid, or treatment administered. --Notification of physician and family, as indicated. --Completion of a falls risk assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess a resident's Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) for proper placement for one sampled resident (Resident #74) out of 18 sampled residents. The facility census was 76 residents. Record review of the facility's Confirming Placement of Feeding Tubes policy revised November 2018 showed: -The exit site of the feeding tune would be marked (by incremental marking on the tube or by documented tube length) at initial time of placement. -If a change in the incremental length was observed, use additional method(s) to test whether the tube was properly positioned: --Observed for symptoms of elevated gastric residual volume (GRV): [...]

Inspectors wroteBased on observation and interview, the facility failed to remove a buildup of dust on the ceiling above the food preparation table; to remove a buildup of food debris and dust from under the six burner stove, the steam table and the food preparation table; to remove a heavy buildup of grease and burnt-on food from the metal grates that sit above the actual gas burners; and to maintain the gaskets (a material such as rubber or a part used to make the area between two pieces of a material resist the flow of fluid such as air or water) of the reach-in refrigerator in good repair. This practice potentially affected all residents. The facility census was 87 residents. 1. Observations on 5/1/23 from 9:15 AM through 12:50 PM, showed: -A torn gasket on reach-in Fridge identified as RI, was torn on both doors of the reach in refrigerator. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding infection control monitoring and tracking of infections in the facility which potentially affected all residents in the facility. There were 19 residents in the sample and the facility census was 87 residents. Record review of the Infection Surveillance-Overview from the facility's Infection Prevention and Control Manual dated 2020 showed, -Data Analysis will assist the facility in: --Determining the origin of infection. --Comparing current and past infection control surveillance. --Comparing the reported incidence of infections by type and location. --Determining need for additional education and staff competency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure handwashing was completed to prevent cross contamination during incontinence care for one sampled resident (Resident #85); to ensure hand hygiene was completed during blood glucose monitoring, to ensure reusable devices were properly cleaned to prevent cross contamination, and to provide appropriate wound care for one sampled resident (Resident #88); to maintain an effective infection control program including tracking and trending of infections; and failed to ensure residents who admitted to the facility had Tuberculosis (TB- an infectious bacterial disease characterized by the growth of nodules in the tissues, especially the lungs) testing completed and up to date for four sampled residents (Residents #75, #73, #70, and #27) on admission out of 19 sampled residents. The facility census was 87 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process to monitor antibiotic usage including prescribing and documentation of the indication, dosage, and duration of the use of antibiotics. This failure had the potential to affect all residents at the facility. The facility census was 87 residents. Record review of the facility policy titled Antibiotic Stewardship Program Policy dated 6/3/21 showed: -The facility was to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. -Antibiotic stewardship actions were conducted to enable or to measure these key elements of care: --Knowing when to be concerned about an infection in a resident. --What clinical and historical information to gather for the provider. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy and dignity was preserved during incontinence care for two sampled residents (Resident #85, and #20) and one supplemental resident (Resident #66) out of 19 sampled residents and five supplemental residents. The facility census was 87 residents. Record review of the facility's undated Notice of Resident Privacy/Dignity Practices showed: -Dignity refers to treating residents with respect. Examples include respecting the resident's wishes, responding to their need and treating them as individuals. -Dignity also means respecting their rights, giving them freedom of choice .providing them privacy and their own personal space. -For those with cognitive impairments, it is important that the preferences they had are still acknowledged even though they may no longer be able to express their preferences. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling vents in the shower rooms of 100 Hall, 200 Hall and the 500 Hall, free of a heavy buildup of dust; and to maintain the base of a standup lift (a medical device that assists individuals with limited mobility in standing up from a seated position. This type of lift is designed for individuals who find it difficult or impossible to stand up without assistance due to a variety of medical conditions or disabilities) without a two inch (in.) crack. This practice potentially affected at least 60 residents who may obtain their showers in the facility shower rooms and seven residents who needed the assistance of a stand-up lift. The facility census was 87 residents. 1. Observation with Maintenance Assistant A on 5/2/23, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety while on the toilet that resulted in a fall with injury for one sampled resident (Resident #27) out of 18 sampled residents. The facility also failed to maintain hot water temperatures in resident rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 4101, 402, 403, 405, 406, 407, 408, 409, 502 and 504 below 120 ºF (degrees Fahrenheit) on 5/1/23. This practice potentially affected 33 residents who resided in resident rooms served by Nurse's Station 2. The facility census was 87 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store oxygen face masks, tubing, nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), in a plastic bag to prevent cross-contamination when not in use for one sampled resident (Resident #5) and one supplemental resident (Resident #49); to store a bi-level positive airway pressure (bi-pap a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) mask in a plastic bag for one supplemental resident (Resident #48); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct dosage of Insulin(a hormone used to treat high blood sugar) was administered by not priming the insulin pen (an injection device with a needle that delivers insulin into the tissue) before administering insulin to one sampled resident (Resident #88) out of 19 sampled residents. The facility census was 87 residents. Record review of the facility's undated policy titled Procedure for Insulin Administration using Insulin Pen showed: -Once a new needle was attached, staff were to set the pen's dial to 2 units, hold the pen vertically with the tip facing the ceiling, and press the dose button. -Staff were to visualize a drop or stream of insulin at the tip of the needle to ensure all air had been removed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were maintained by placing an indwelling catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that held drained urine) at or above the level of the bladder during wound care for one sampled resident (Resident #2) and by not providing catheter care and not obtaining a physician's order for an indwelling catheter for one sampled resident (Resident #88), who were both at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 19 sampled residents. The facility census was 87 residents. Record review of the facility Catheter Care policy dated 6/13/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by the off-going and on-coming nursing staff per the facility policy. The facility census was 80 residents. Record review of the facility's undated Medications-Narcotics policy showed: -Narcotics should be counted at the beginning and end of every shift by the unit charge nurse or Certified Medication Technician(CMT). -Both nurses or CMTs should date and sign the count log in the cart's narcotic notebook. -The Director of Nursing (DON) should be notified immediately if there were any discrepancy in the narcotics count. -If the unit charge nurse or CMT had to leave before the end of a shift, he/she should count the narcotics with the oncoming charge nurse or CMT before he/she left the facility. [...]