Bedford Co Nursing Home

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for the one resident in the survey sample (Resident #1).

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice during a medication pass on one of three units (100 unit).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to follow physician orders for one of twenty-four residents in the survey sample (Resident #10).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed four errors out of thirty three opportunities resulting in a 12.5% error rate. 1. Resident #69 (R69) Administration instructions were not followed, and the wrong dose of Flovent was administered. 2. Resident #61 (R61) extended release Metoprolol was crushed prior to administering, and Eliquis was not administered timely. The Findings Include: 1. During a medication pass and pour observation conducted on 815/23 at 8:00 AM, license practical nurse (LPN #1) began pulling medications out of the medication cart for R69 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Flovent inhaler 44 MCG (micrograms). [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide an adaptive cup for one of twenty-four residents in the survey sample (Resident #180).

Inspectors wroteBased on facility document review and staff interview, the facility staff failed to submit payroll data prior to the deadline for quarter January 1 through March 31, 2023.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure professional standards of practice by a hospice provider for one of 19 residents in the survey sample, Resident #14. Records of weekly hospice visits for Resident #14, including nursing assessments and direct-care services were not provided to the facility as required in the hospice services agreement.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASARR) was completed before admission to the facility for one of 19 residents in the survey sample, Resident # 44.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 19 in the survey sample, Resident #36. Resident #36's care plan was not reviewed and revised for code status change.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to clarify a physician's order prior to administration of medication to one of seven residents in the medication pass, Resident #67. Resident #67 was administered ICaps multivitamin when the physician's order was for ICaps AREDS.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to use footrest and a foot board/plate on a wheelchair to prevent accidents resulting in a clavicle fracture for one of 21 residents in the survey sample, Resident #15; and failed to ensure physician orders and ensure an assessment was completed for the use of a Broda specialized wheelchair, for one of 21 residents sample, Resident #37.

Inspectors wrote2. Resident #50 was admitted to the facility on [DATE]. Diagnoses for Resident #50 included Glaucoma, diabetes, dementia, and pneumonia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/24/19. Resident #50 was assessed as having short-term memory loss and moderately impaired cognitive skills. On 09/03/19 at 3:37 PM, an interview was conducted with Resident #50's husband. During the interview the husband mentioned that Resident #50 needed to be fed and sit up for an hour after eating due to having had aspiration pneumonia in March. Review of Resident #50's physician's orders evidenced an active order dated 3/17/19 for Aspiration Precautions. [...]

Inspectors wroteBased on observation, staff interview, and clinical document review, facility staff failed to follow physician orders for 5 of 21 residents in the survey sample. Facility staff did not apply an edema sleeve for Resident #12, failed to apply geri sleeves for Resident #50, failed to notify the physician of elevated blood sugars for Resident #46 and failed to apply TED (compression) stockings for Residents #22 and #74.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a dignified dining experience in the dining room for one of 20 residents on the second unit, Resident #9. Resident #9, who needed to be fed by staff, was kept waiting for seventeen minutes while all the other residents at the table and in the dining room were served and ate their meal.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for two of 21 residents in the survey sample. Treatment records for Resident #22 and #74 were signed off by nursing indicating application of physician ordered devices when the items were not actually in use.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to apply a physician ordered hand brace for one of 21 residents in the survey sample (Resident #22).

Inspectors wroteBased on observation staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner. Seventeen 0.5 oz. (ounce) cartons of Lactaid milk, with expired discard dates, were stored and available for use in the main kitchen's walk-in refrigerator.

Inspectors wroteBased on review of the facility's Infection Prevention and Control Program, the Antimicrobial Stewardship Program, and staff interview, the facility failed to ensure both programs were reviewed and approved by the Medical Director, and failed to ensure both programs were formally adopted as facility policy.