Beecher Manor Nrsg & Rehab Ctr

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from exploitation and sexual abuse by V5 (Maintenance Assistant). This applies to 1 resident (R1) reviewed for abuse in a sample of 5 residents. V5's abuse of power and manipulation resulted in mental anguish for R1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meal delivery in a timely manner to ensure palatability. This applies to 3 of 3 residents (R4, R5 and R7) reviewed for dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing services were consistently implemented in accordance with therapy recommendations and resident needs rather than residents approaching MDS (Minimum Data Set) assessment review periods. The facility failed to provide restorative programming when restorative aids were reassigned to work on the floor and given an assignment to perform patient care/ staffing duties. This applies to 11 of 13 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R12, R13) reviewed for restorative therapy services.

Inspectors wroteBased on interview and record review the facility failed to ensure privacy for 1 of 4 residents (R2) reviewed for personal privacy. This failure resulted in R2 feeling unsafe in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a residents nutritional needs were met. This applies to 1 resident (R1) reviewed for significant weight loss in the sample of 9.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure a resident was transferred in a safe manner, resulting in a fall. This applies to 1 of 5 residents (R1) reviewed for falls in a sample of 5.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow fall prevention interventions for residents at high risk of falls for two of six residents (R4, R8) reviewed for falls and safety.

Inspectors wroteBased on interview, and record review, the facility failed to have safety measures in place to prevent a fall. This failure led to a resident sustaining a 3-centimeter laceration to the left parietal scalp, requiring 3 staples for closure. This applies to 1 of 5 residents (R1) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 4.

Inspectors wroteBased on observation. Interview and record review the facility failed to maintain the kitchen in a manner that would prevent foodborne illness. This applies to 112 residents that receive their meal from dietary services.

Inspectors wroteBased on observation, interview and record review the facility failed to provide hygiene care and maintenance. This applies to 4 of 6 residents reviewed for ADL (Activities of Daily Living) in a sample of 37.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have proper fall precaution measures in place for 4 residents (R33, R14, R69 & R52) who are at risk for falls in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Enhance Barrier Precautions (EBP) Guidelines by staff not wearing gowns during incontinent care to EBP residents and not having a trash can inside the resident room and near the exit for discarding PPE after removal. The facility also failed to maintain effective hand hygiene during resident care. This applies to 4 of 4 residents (R1, R56, R40, and R80) reviewed for infection control practices in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ambulatory resident with continuous oxygen (a portable oxygen tank holder). This applies to 1 of 1 residents (R76) reviewed for oxygen in a sample of 37.

Inspectors wroteBased on interview and record review the facility failed to maintain current and accurate advanced directives for 2 residents (R69, R115) in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility confined a resident to her bed by placing interconnected bed bolsters on both sides of the bed and two upper side rails up. This applies to 1 of 1 resident (R81) reviewed for physical restraint in a sample of 37.

Inspectors wroteBased on record review and interview the facility failed to provide written notice of the facility's bed hold policy to 1 resident (R69) or representative before being transferred to the hospital in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to provide wound care. This applies to 1 of 3 residents (R1) reviewed for wound treatment and care in a sample of 37.

Inspectors wroteBased on observation, interview and record review the facility failed to provide restorative care services. This applies to 2 of 2 residents (R65 and R74) reviewed for rehab services in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label, date, and discard old food and beverages from resident's personal refrigerators. This applies to 2 of 2 residents (R34 and R49) in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a pest-free environment to residents by having house flies and gnats in the resident rooms and common areas. This applies to all 117 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide safe bed mobility assistance for one (R1) of three resident reviewed for resident injury and siderail use in a sample of seven. These failures resulted R1 incurring a right femur fracture, a nasal fracture and a laceration requiring sutures. This was identified as past non-compliance that occurred from 04/02/2024 to 04/05/2024.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged accusation of misappropriation of resident narcotics. This applies to 10 of 10 residents (R1-R10) reviewed for misappropriation of property in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to have evidence of a thorough investigation regarding allegation of misappropriation of resident narcotics. This applies to 10 of 10 residents (R1-R10) reviewed for misappropriation of property in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a wound dressing was in place for a resident with a stage 4 pressure ulcer. This applies to 1 out of 3 residents (R2) reviewed for pressure wounds in a sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) has the required professional training to perform the role. This failure has the potential to affect all 114 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 7 of 7 residents (R3, R23, R40, R50, R57, R89, R110) reviewed for ADL (activities of daily living) in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve sauce over mechanically ground chicken as shown on menu spreadsheet. This applies to 5 of 5 residents (R67, R88, R92, R99, R110) observed for dining in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of care, and use of PPE (Personal Protective Equipment) when entering an isolation room. The facility also failed to ensure a resident had a physician's order for isolation, and the indwelling urinary catheter bag was not touching the floor. This applies to 6 of the 24 residents (R24, R40, R48, R57, R60, R67) reviewed for infection control in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor and track the status of influenza (flu) and pneumococcal (pneumonia) vaccinations to ensure eligible residents were offered a vaccine or residents who consented to receive a vaccine actually received it. This failure affected 5 out of 5 (R2, R48, R60, R66, R90) residents reviewed for influenza and pneumococcal vaccinations in the total sample of 24 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply a splint and provide treatment plan as recommended and ordered to prevent contractures. This applies to 1 of 3 residents (R24) reviewed for range of motion in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence and catheter care in a manner that would prevent potential urinary tract infection and reduce friction at the catheter insertion site. This applies to 4 of 7 residents (R40, R57, R60, R67) reviewed for incontinence and catheter care in the sample of 24.

Inspectors wroteBased on interview and record review the facility failed to ensure that accurate documentation of controlled drugs was maintained. This applies 6 of 6 residents (R2, R5, R12, R29, R66, R99) reviewed for controlled medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have a facility wide IPCP (Infection Prevention Control Plan) and failed to provide an Infection surveillance plan. The facility also failed to follow standard infection control practices during provisions of care related to hand hygiene and gloving for R20, R48, R55 and R77. This applies to all 94 residents residing at the facility.

Inspectors wroteBased on interviews and record reviews the facility failed to have an ongoing antibiotic stewardship program. This applies to all 94 residents residing in the facility.

Inspectors wrote3. R62 was admitted to the facility on [DATE] with multiple diagnoses which included resistance to Vancomycin-VRE (Vancomycin-resistant Enterococcus), unspecified and neuromuscular dysfunction of the bladder, based on the face sheet. R62's admission MDS (minimum data set) dated March 13, 2022 shows that the resident is cognitively intact and would require limited assistance from the staff with most of his ADL (activities of daily living). R62 is on contact precaution due to diagnosis of CRE (carbapenem-resistant enterobacterales) of the wound. On April 19, 2022 at 11:29 AM, R62 was in bed alert, oriented and verbally responsive. R62's urinary catheter tubing was observed with scattered white sediments. After providing pressure injury treatment to R62's coccyx area, V3 (Nurse) and V7 (CNA/Certified Nursing Assistant) turned and repositioned R62. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to monitor and assess the IV (intravenous) antibiotic administration and failed to disconnect and flush the midline catheter after completion of the IV antibiotic administration. This applies to 1 of 5 residents (R72) reviewed for IV medication administration in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform treatment for pressure ulcers that would prevent potential development of infection. This applies to 2 of 8 residents (R55 and R62) reviewed for pressure ulcers in a total sample of 20 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that assessment, monitoring, and targeted behavior is being documented for a resident who is receiving psychotropic medications. This applies to 1 of 3 residents (R45) reviewed for psychotropic medications in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all staff were fully vaccinated for COVID-19. This has the potential to affect all 94 residents in the facility.