Bedford Court Healthcare Cent.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store and process linens to prevent the spread of infection. This was evident for 1 out of 1 observation made in the facility's laundry room.

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility failed to ensure that controlled substances were consistently accounted for and documented through the required dual nurse signatures during shift-to-shift narcotic counts. This was evident for 2 (Choice and Independent) out of 3 units during the facility's recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that food items were stored in a manner that maintained the integrity of the specific items. This was evident for 1 (initial observation) of 2 of the kitchen areas upon facility entry.

Inspectors wroteBased on review of facility documents and interviews, it was determined that the facility failed to: 1) conduct quality assurance meetings on a quarterly basis, and 2) ensure the presence of required quality assurance committee members in meetings. This was evident during the quality assurance and performance improvement task conducted as part of the recertification survey process.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure staff received ongoing Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was identified in 5 of 5 employee files reviewed during the facility's recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that that the facility failed to refer a resident for a PASARR evaluation review after a new mental health diagnosis. This was evident for one (Resident # 4) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to develop and/or update residents care plan. This was for 2 (Resident #1 and #49) out of 3 residents reviewed for care plan during the recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to maintain professional standards of practice related to: 1) oxygen orders and 2) providing sufficient documentation to support a new mental health diagnosis. This was evident for 2 (Resident #1 and #4) out of 6 residents reviewed for respiratory orders and unnecessary medications during the recertification survey.

Inspectors wroteBased on record review, observations and staff interview, it was determined that the facility failed to maintain good grooming and personal care services for Resident # 6. This was evident for one (Resident # 6) out of one resident reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on interviews, observations and record reviews, it was determined that the facility failed to: 1) provide appropriate treatment to maintain an individual's limited range of motion, and 2) evaluate a resident for therapy services to prevent further decline in the range of motion. This was evident for 1 (Resident #19) out of 6 residents reviewed for position and mobility during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to verify the accuracy of hospital discharge paperwork prior to placing admission medication orders for newly admitted residents. This was evident for 1 (Resident #40) out of 20 residents reviewed during the survey.

Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to 1) obtain physician orders for residents to receive Continuous Positive Airway Pressure (CPAP) treatment and 2) maintain Quality of Care. This was evident for 3 (Resident #17, #8 and #292) of 24 residents reviewed during the annual survey

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication. This was found to be evident for 3 out of 3 medication carts observed during the re-certification survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchens.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to properly dispose of waste in the kitchen area in a manner to prevent contamination and the attraction of pests. This was evident for 1 out of 2 kitchen areas in the facility.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the required staff members were present for each of the monthly Quality Assurance (QA) Committee meetings. This was evident during a review of the Quality Assurance and Performance Improvement (QAPI) program during the recertification survey.

Inspectors wroteBased on observation and interviews with residents and staff, it was determined that the facility failed to respect a resident's dignity. This was evident in 1 (Resident #8) out of 6 residents observed for dignity.

Inspectors wroteBased on observations and interview, it was determined the facility failed to ensure that the location of the most recent state survey results and plan of correction were posted in a place readily accessible to residents, family members and visitors. This was evident during the facility's recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide evidence that an advance directive was offered to the residents. This was evident for 2 (Resident #22 and #37) of 4 residents reviewed for advance directives during the recertification survey.

Inspectors wroteBased on review of the facility policy and interviews it was determined that the facility failed to ensure that grievance forms were accessible. This was found to be evident for 1 (Resident #244) out of 1 Resident reviewed for the grievance policy.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for the use of a splint. This was evident for 1 (Resident #37) of 32 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents. This was evident for 1 (Residents #17) of 24 residents selected for investigation during the survey process.

Inspectors wroteBased on record review and interview of staff it was determined that the facility failed to ensure Activities of Daily Living (ADL) was provided. This was found to be evident for 1 (Resident #244) out of 14 Residents reviewed for ADL care.

Inspectors wroteBased on observations, clinical record review, and staff interviews it was determined that the facility failed to maintain oxygen therapy equipment according to professional standards of practice. This was found to be evident for 2 (#24 and #11) out of 2 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #3 and #8) of 24 residents reviewed the recertification survey.

Inspectors wroteBased on observations, and interviews, it was determined that the facility failed to 1) keep a sanitary environment and 2) ensure the facility's equipment was functional. This was evident in the laundry room and for 1 (Resident #8) out of 14 resident rooms observed during the facility's recertification survey.

Inspectors wroteBased on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to maintain accurately documented electronic records. This finding was evident for 1 of 15 residents selected for review during the survey (Resident #93).

Inspectors wroteBased on surveyor review of the clinical record and surveyor interview, it was determined that the facility failed to offer a pneumococcal immunization to 1 of 5 residents selected for immunization review (Resident #2).