Bedford Care Center of Mendenhall

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to respond to Resident Council concerns and recommendations for three (3) of (3 ) residents interviewed. (Residents #11, #22, and #26). Findings Include:A record review of the facility policy titled, Resident Council Meeting, with a revision date of 10/1/22, revealed, .7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate decisions to the Council .At 9:25 AM on 6/23/26, during an interview, Resident #22 reported that upon admission less than a year ago, she was told that Certified Nursing Assistants (CNAs) would make her bed daily, as she is unable to do so due to chronic lower back problems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective infection prevention and control program for two (2) of three (3) residents observed for infection prevention practices related to medication administration and wound care. (Residents #4 and #42). Findings Include:Record review of the facility policy Handwashing/Hand Hygiene revised 8/2/22 revealed, This facility considers hand hygiene the primary means to prevent the spread of infection and recommends to perform hand hygiene after removing gloves .Record review of the facility policy Enhanced Barrier Precautions revised 3/27/26 revealed, Policy: [...]

Inspectors wroteBased on observations, interviews, record reviews and facility policy review the facility failed to implement comprehensive care plans for two (2) of (15) sampled Residents. Residents #14 and Resident #42.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure residents were transferred using the care planned mechanical lift, resulting in Resident #14 being transferred with an inappropriate sit to stand lift rather than the required total lift for one (1) of three (3) residents who required a lift for transfers.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors by failing to accurately reconcile hospital discharge medications and ensure timely and accurate medication administration, which resulted in missed doses of prescribed antibiotic therapy and subsequent rehospitalization for wound infection and dehiscence (surgical incision that opens or pulls apart) for Resident #1 and duplicate administration of antihypertensive medications for Resident #2, affecting two (2) of four (4) sampled residents. Findings Include:Review of the facility's policy, Administering Medications revised 8/02/22, revealed, .Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation.3. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to follow infection prevention guidelines by improperly implementing enhanced barrier precautions, failing to adhere to handwashing/hand hygiene practices during care and failed to ensure clean and soiled items were not stored together in a biohazard room for two (2) of four (4) days of survey that affected Resident #13 and Resident #31. Findings Include: A record review of the facility's Enhanced Barrier Precautions policy dated 3/7/24 revealed .Policy Explanation and Compliance Guidelines .2. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. [...]

Inspectors wroteBased on observations, interviews, record reviews and facility policy review the facility failed to ensure resident rights were honored as evidenced by Resident #44 was not allowed to get out of bed as requested and residents not receiving preferred snacks at bedtime for five (5) of 31 sampled residents reviewed for choices. Resident #26, Resident #33, Resident #40, and Resident #41 and Resident #44 Findings Include: Resident #44 A record review of the facility's Resident Rights with a revision date of 6/1/23 revealed .4. Respect and dignity .c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . On 02/03/25 at 11:37 AM, in an interview and observation Resident #44 in bed. She stated she wants to get up, but they (facility staff) won't get me up. [...]

Inspectors wroteBased on observations, interviews, facility policy review, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for two (2) of five (5) residents observed for care (Resident #13 and Resident #31).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure residents who use enabling devices have physician orders as part of the professional standard of practice for one (1) of (19) residents who use enabling devices in the facility. Resident #52.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions to prevent burns and for the use of tobacco for one (1) of seven (7) sampled residents. (Resident #1) The facility's failure to develop comprehensive care plan interventions resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia - left side, Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision to prevent a burn from hot coffee for one (1) of seven (7) sampled residents, with the potential to affect all residents who drink coffee in the Dining Room. Resident #1 The facility's failure to ensure adequate supervision resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's right for self-determination as evidenced by facility staff taking a resident's chewing tobacco without notice, which he was previously granted permission to have, and resulted in the resident crying and begging in distress and continued fear of staff taking away his tobacco for one (1) of three (3) residents sampled for tobacco usage. (Resident #1)

Inspectors wroteCI MS #23522 Based on staff interviews, record reviews, and facility policy and procedure reviews, the facility failed to implement the care plan for a two (2) person transfer using a full body lift, resulting in an injury to Resident #1 for one (1) of three (3) care plans reviewed for transfers. Based on implementation of the facility's corrective actions initiated on 11/09/23-11/12/23, this was determined to be Past Non-Compliance (PNC). Findings Include: The facility policy and procedure titled Using the Care Plan dated revised 8/2/22 revealed: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident The facility policy and procedure titled Comprehensive Care Plans dated revised 8/24/22 revealed: Policy: [...]

Inspectors wroteCI MS 23522 Based on record reviews, interviews, and facility policy and procedure review the facility failed to ensure a resident was free of accidents and/or hazards during transfer when staff physically lifted and transferred Resident #1 from her bed to her wheelchair without using the required full body lift with two (2) person (s) to assist, resulting in a fracture of the left tibia and fibula and a left non-displaced intertrochanteric femur fracture for one (1) of three (3) residents reviewed for accident/hazards. Resident #1. Based on implementation of the facility's corrective actions on 11/09/23 through 11/12/23, this was determined to be Past Non-Compliance.

Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to keep the call light within the resident's reach for two (2) of three (3) observations. Resident #8.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to ensure a dignified living environment for a resident who had signs regarding her care posted in view of visitors and other residents for one (1) of 15 sampled residents. Resident #23 Findings Include: Review of the facility's Resident Rights, revised 6/1/23, revealed .7. Privacy and confidentiality. The resident has a right to .confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care . On 09/05/23 at 2:49 PM, during an observation of Resident #23, there was a handwritten sign located on her personal refrigerator, within view of other residents and visitors, which indicated Thickened Liquids. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure that tube placement was checked prior to flushing the enteral feeding tube with water for one (1) of (1) observations of enteral feedings.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #8 Findings Include: Review of the facility's policy, Oxygen Administration, with revised date of 08/02/22, revealed, Purpose .The purpose of this procedure is to provide guidelines for safe oxygen use . Equipment and Supplies .The following equipment .will be necessary when performing this procedure .4. No Smoking/Oxygen in Use signs . Steps in the Procedure . 2. Place an Oxygen in Use sign on the outside of the room entrance door. Close the door . On 09/05/23 at 11:21 AM, an initial observation of Resident # 8, revealed the resident was receiving oxygen by way of nasal cannula using an oxygen concentrator. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to discard expired medications and ensure that opened multi-dose vials were dated when opened for two (2) of two (2) medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the possible spread of infection when a nurse dispensed medication into her bare hands during the administration of medications for two (2) of nine (9) residents observed for medication administration. Residents #10 and #41.

Inspectors wroteBased on interviews, record review and facility policy review, the facility the facility failed to provide influenza and/or pneumococcal vaccinations as requested per their signed consents for four (4) of 21 sampled residents. Resident #16, #46, #47 and #51.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to administer the COVID-19 vaccine as requested and consented for one (1) of 21 residents reviewed for COVID-19 vaccinations. Resident #51.

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to provide a private meeting space for the resident council members monthly meetings for six (6) of six (6) resident council meetings reviewed. Findings Include: Review of the facility's policy, Resident Rights, revised 6/1/23, revealed, .Policy Explanation and Compliance Guidelines .7. Privacy and confidentiality .a. Personal privacy includes accommodations .meeting of family and resident groups . During the resident council group meeting on 9/5/23 at 2:00 PM, the resident group stated they were not allowed privacy during the resident council meetings. The meetings were held in the resident and staff dining room, which was a common area, and the group complained that staff always interrupt the meeting. [...]

Inspectors wroteBased on observations, interviews and facility policy review the facility failed to provide contact information for filing grievances or complaints concerning any suspected violation of the State or Federal nursing facility regulations for three (3) of three (3) days of survey. Findings Include: Review of the facility's policy, Resident Rights, revised 6/1/23, revealed, The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility .Policy Explanation and Compliance Guidelines .8. A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility . Information and communication .g. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure staffing information was posted in a prominent place readily accessible to resident and visitors for three (3) of three (3) survey days, having the potential to affect all residents residing at the facility.