Beech Tree Health and Rehabilitation

Inspectors wroteBased on review of the facility abuse policy, medical record review, review of facility investigations, corrective action plans, and interviews, the facility failed to prevent resident abuse for 8 residents, (Residents #1, #2, #3, #4, #5, #6, #7, #8) of 16 residents sampled for abuse or neglect. The facility failures occurred when it failed to prevent resident versus resident altercations which resulted in residents striking other residents (physical abuse), or nonconsensual sexual contact between cognitively impaired persons (sexual abuse).

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, hospital record review, and interviews, the facility failed to execute a safe and orderly involuntary discharge for 1 resident, (Resident #1) of 4 Residents reviewed for admissions, transfers and discharges.

Inspectors wroteResident #24 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Alzheimer's Disease, Dementia, Abnormalities of Gait and Mobility, and Muscle Weakness. Review of the comprehensive care plan for Resident #24 dated 8/22/2016, last revised on 4/23/2021, showed .I have impaired cognitive function r/t Dementia . Resident #24's care plan was not updated to reflect the resident to resident altercation on 2/9/2024. Review of the quarterly MDS assessment dated [DATE], showed Resident #24 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #24 exhibited no behavioral symptoms. Review of the SKIN- Head to Toe Weekly Skin Checks for Resident #24 dated 2/8/2024, showed the resident had no areas of skin impairment. [...]

Inspectors wroteResident #91 was admitted to the facility on [DATE] with diagnoses including COVID-19 and Vascular Dementia with Agitation. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Review of the care plan dated 1/12/2024, showed Resident #91 had .impaired cognitive function/dementia .Administer medications as ordered. Observe/document for side effects and effectiveness . Review of the care plan dated 1/20/2024, showed Resident #91 had .Abusive verbal attacks on staff and others . There were no interventions for this focus on Resident #91's care plan. Review of the care plan dated 1/22/2024, showed Resident #91 had .Behavior Care Plan .Potential for impaired or inappropriate behaviors related to Dementia . [...]

Inspectors wroteReview of a hospital Discharge Documentation for Resident #40 dated 2/13/2024, showed Resident #40 previously resided in an assisted living facility where she was involved in an altercation with another resident and a staff member prior to this hospitalization. The assisted living facility would not accept the resident back due to her aggressive and irrational behaviors. Resident #40 was discharged from the hospital to the current facility where she resided. Resident #40 was admitted to the secure unit at the facility on 2/13/2024 with diagnoses including Dementia with Other Behavioral Disturbance, and Depression. Review of the Abuse Screening Indicator for Resident #40 dated 2/13/2024, showed she was evaluated in 5 categories to determine abuse risk factors. The category for History of abuse prior to admission documented, .Undetermined . [...]

Inspectors wroteBased on facility policy review, medical record review, observations and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 9 residents (Residents #91, #40, #24, #73, #44, #46, #39, #20, and #78) of 37 residents reviewed for comprehensive care plans. The facility failed to address Resident #40's history of aggressive behaviors, with appropriate interventions. The facility failed to develop and implement a person-centered care plan related to Resident #91's wandering behaviors. [...]

Inspectors wroteBased on facility policy review, job description review, facility documentation review, medical record review, and interview, the facility's Administration failed to provide effective leadership and oversight to ensure effective systems were in place to ensure residents were free from abuse, identify serious outcomes related to abuse, investigate allegations of abuse, determine a root cause analysis (RCA) for abuse, develop and implement person centered care plans, report allegations of abuse to the local and state designated authorities, and discuss concerns related to abuse in Quality Assurance Performance Improvement (QAPI) and Governing Body (GB) meetings. [...]

Inspectors wroteBased on facility policy review, job description review, facility documentation review, medical record review, observation, and interview, the facility's Governing Body failed to provide effective leadership and oversight of the facility's Administration to ensure residents had the right to be free from abuse, failed to identify resident to resident altercations or injuries of unknown origin as the potential for abuse, failed to investigate resident to resident altercations and an injury of unknown origin, and failed to report resident to resident altercations and injury of unknown origin to the local and state designated authorities as required for 4 residents (Residents #39, #91,#24, and #46) of 37 residents reviewed for injury of unknown origin and abuse. [...]

Inspectors wroteBased on facility policy review, facility documentation review, medical record review, observation and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify quality deficiencies, investigate, report, perform a root cause analysis to identify serious outcomes, develop and implement person centered interventions for 4 of 37 residents (Residents #39, #91, #24, and #46) related to an injury of unknown origin and abuse. The facility's failure to have an effective QAPI program resulted in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). [...]

Inspectors wroteBased on facility policy review, facility documentation review, and interview, the facility failed to provide quarterly financial statements for 5 residents (Residents #8, #27, #28, #34, and #78) with personal fund accounts of 88 residents reviewed with personal fund accounts managed by the facility.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to post accurate staffing information to reflect daily staffing levels on 7 days of 31 days reviewed for staffing.

Inspectors wroteBased on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 4 Residents (#39, #78, #20, and #46) of 31 residents reviewed for MDS assessments.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to offer hand hygiene assistance to residents prior to meals for 5 residents (Residents #78, #203, #50, #54, and #79) observed in 1 of 2 dining areas and 2 of 3 resident units observed for meal tray distribution.

Inspectors wroteBased on medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) timely after a new mental health diagnosis for 2 residents (Residents #27 and #78) of 12 residents reviewed for PASRR.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to provide nail care during Activities of Daily Living (ADL) care for 1 resident (Resident #7) of 31 residents reviewed for ADL care.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to identify and complete a fall investigation for 1 Resident (#39) of 7 residents reviewed for falls.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to develop a Dementia care plan for 1 resident (Resident #84) of 9 residents reviewed for Dementia Care.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure the physician or nurse practitioner acted upon a recommendation from the consultant pharmacist for 1 resident (Resident #27) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure the medication error was less than 5 percent. There were 26 opportunities with 2 errors resulting in a 7.69% medication error rate. The errors involved 2 of 8 residents (Residents #20 and #92) in the sample.

Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interviews the facility failed to protect the resident's (Resident #2's) right to be free from physical abuse by Resident #3 of 3 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were stored and administered safely for 1 resident (Resident #8) of 5 residents reviewed for medication administration when medications were found lying in the resident's room on 2 days (11/14/2021 and 11/15/2021).

Inspectors wroteBased on facility policy, observation and interview the facility failed to maintain a clean and sanitary environment in 5 of 16 bathrooms and 1 of 4 shower rooms observed.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper administration of a medication for 1 resident (#33) of 1 resident reviewed for self-administration of medications of 18 sampled residents.

Inspectors wroteBased on review of facility policy, observation, and interview the facility failed to maintain a sanitary environment for dining for 2 residents (#74 and #384) in 1 of 2 dining rooms observed on the secured unit.