Bedford Care Ctr-Monroe Hall

Inspectors wroteBased on observation, interview record review and facility policy review, the facility failed to assure the resident's dignity in accordance with professional standards as evidenced by staff were standing while assisting a resident with feeding for one (1) of 20 residents sampled. Resident #6Findings include:A review of the facility's policy, Assisting with Meals, revised 8-2-22, revealed Policy Statements Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Policy Interpretation and Implementation .3. Residents Requiring Full Assistance .c. Residents who cannot feed themselves will be fed with attention to .dignity, for example: [...]

Inspectors wroteBased on observations, interviews, and policy reviews, the facility failed to ensure food safety on one (1) of four (4) survey days. Specifically, the facility failed to remove out-of-date grape juice from the reach-in cooler, failed to remove (34) four-ounce containers of expired yogurt from the refrigerator, and failed to prevent the service of expired food items to residents. Findings Include:A review of the facility's policy, Food Safety Requirements, revised 11/21/22, revealed, .Food will be served in accordance with professional standards for food service safety. Policy Interpretation and Implementation.8c. Additional strategies to prevent foodborne illness include.iv. Labeling, dating, and monitoring refrigerated foods so it is used by the use-by date or discarded. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident was free from neglect, as evidenced by, on 10/21/24, at approximately 2:45 PM, after returning to an outing at a local fair, a resident was left in the facility's transportation van until approximately 5:00 PM, for one (1) of three (3) sampled residents.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to report a violation of neglect within 24 hours when the facility was notified that a resident had been left in a facility van for an undetermined amount of time for one (1) of three (3) residents.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to conduct a thorough investigation related to a resident who was left on the facility's transportation van upon return from an outing for one (1) of 3 (three) sampled residents.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to transmit a Discharge Minimum Data Set (MDS) Assessment in a timely manner for one (1) of 19 residents reviewed for MDS assessments. (Resident # 58) Findings Include: Record review of the facility's policy, Resident Assessment Instrument, revised 06/17/2022 revealed, POLICY STATEMENT: A comprehensive assessment of a resident's needs shall be made .periodically .POLICY INTERPRETATION AND IMPLEMENTATION: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews . Record review of the admission Record revealed the facility admitted Resident #58 on 10/31/23 and he had diagnoses including Atrial Fibrillation. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed ensure a nebulizer mask was stored in a designated storage bag one (1) of one (1) resident reviewed for respiratory care. Resident #179.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to provide a written notice of transfer to the Responsible Representative (RR) for four (4) of four (4) residents reviewed. Resident #23, Resident #63, Resident #65 and Resident #67. Findings Include: Record review of the facility's policy, Transfer or Discharge, Emergency with a Revised Date of September 2012 and a Reviewed Date of 1/2022 revealed Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident. 1.e. Notify the representative (sponsor) or other family member as appropriate in writing . Record review of the Re: Written Notice Requirements form revealed .our regulations require this facility to send a Written Notice to Resident Representatives each time a resident is transferred to the hospital or goes out on therapeutic leave . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a Pre-admission Screening (PASSR) Application was completed accurately for one (1) of nine (9) PASSR Applications reviewed. Resident #2. Findings Include: A record review of the facility's policy admission Criteria with a reviewed date of June 2021, revealed, Policy Statement Our facility admits only residents who's medical and nursing care needs can be met Policy Interpretation and Implementation . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. the facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to ensure catheter tubing was anchored to minimize movement or prevent friction and trauma during catheter care and failed to provide catheter care in a manner to prevent infection for one (1) of three (3) catheter care observations. Resident #13.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to prevent the possible spread of infection during medication administration and Percutaneous Endoscopic Gastrostomy (peg) site care for five (5) of seven (7) observations. Findings Include: Record review of the facility's policy, Hand washing/Hand Hygiene, with a revised date of August 2015 and reviewed date of 10/2021 revealed, Policy Statement The facility considers hand hygiene the primary means to prevent spread of infections. Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . 7.b. Before and after direct contact with residents. 7.c. Before preparing or handling medications; .7. m. After removing gloves . [...]