Bell Minor Home, the

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Infection Control, Categories of, the facility failed to ensure staff implemented appropriate infection prevention and control practices related to Enhanced Barrier Precautions (EBP) for one of 13 residents (R) (R8) on EBP. This deficient practice had the potential to increase the risk for transmission of infectious organisms to other residents and staff.

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure that two of 40 sampled residents (R) (R159 and R9), medical providers, and family were timely notified of a change in condition. R159's medical provider was not notified of any changes in the resident's condition, including the lack of pedal pulses. Additionally, R159's family was not made aware of the resident's condition from 8/28/2024 until 9/7/2024. On 9/7/2024, R159's family was concerned about the resident's condition and requested that the resident be transferred to the hospital; however, the facility denied the request. Additionally, on 5/15/2024, the facility identified a change in R9's diabetic foot ulcer; [...]

Inspectors wroteBased on the interviews, record review, and a review of the facility's policies titled Abuse Prevention Policy, Pressure Ulcer Treatment, and Prevention of Pressure Ulcers, the facility failed to ensure residents were free from abuse and neglect for three of six residents (R) (R159, R9, and R360) reviewed for abuse and neglect. (1) The facility neglected to emergently transfer R159 to the hospital per the family's request and failed to notify R159's physician after a change in condition, which resulted in a delay in treatment. (2) The facility failed to notify R9's wound treatment provider of the worsening of the resident's diabetic ulcer. (3) R360 was physically abused by her roommate (R46), who had a history of abusing other residents. These failures caused actual harm and death to the residents. [...]

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure the nursing staff used their clinical skills and judgement to identify and notify the resident's medical provider of the worsening of skin condition for one of three sampled residents (R) (R159). On [DATE] and [DATE], R159 had a change in condition when pedal pulses were unpalpable; however, nursing staff did not identify this as a change in condition, and the resident's medical provider was not notified. On [DATE], R159 was emergently transferred to the hospital, where she expired hours after arriving at the hospital due to complications from the worsening of her skin condition. [...]

Inspectors wroteBased on observation, interview, record review, and a review of the facility's policies titled Prevention of Pressure Ulcers and Pressure Ulcer Treatment, the facility failed to ensure that three of three sampled residents (R) (R104, R2, and R307) did not develop facility-acquired pressure ulcers. The facility failed to prevent the development of significant pressure ulcers for two of the three residents reviewed (R104 and R2). The facility failed to provide oversight, ensuring pressure ulcer assessments were completed, and ensure pressure ulcer treatment was provided in a timely manner and per the physician's orders. 1. R104 did not have preventive interventions in place before [DATE], when a pressure ulcer to the sacrum was identified. [...]

Inspectors wroteBased on interviews, facility policy review, and job description review, the facility administration failed to use resources to ensure residents attained and maintained their highest physical well-being. The facility's Administrator and the Director of Nursing (DON) failed to identify failures from nursing and other facility staff, which caused the actual harm and/or death of residents. 1. The facility's administration failed to ensure that residents' physicians and/or other medical providers were notified after R159 and R9 had changes in conditions related to the worsening of their skin conditions. Cross Reference F580-J 2. The facility's administration failed to ensure residents were free from neglect and abuse. Nursing staff neglected to identify and/or report the worsening of R159's and R9's skin conditions, which led to actual harm and death. [...]

Inspectors wroteBased on observations, interviews, record review, and a review of the facility's policy titled Menu Planning, the facility failed to ensure there was not more than a 14-hour gap between the evening meal (dinner) and breakfast the following day for 99 out of 101 residents (two residents received nutrition via tube feeding). The planned meal gap between dinner and breakfast the following day was 15 hours. A substantial evening snack was not provided, and the resident group had not approved of the 15-hour gap between dinner and breakfast. This created the potential for residents to experience hunger while waiting for breakfast.

Inspectors wroteBased on observations, interviews, record review, and a review of the facility's policy titled Policy: Hand Washing, the facility failed to maintain and practice food service principles in the kitchen in a manner to prevent the potential spread of food borne illness for 99 out of 101 total residents (two residents received nutrition via tube feeding). Specifically, staff did not adhere to hand hygiene principles when touching ready-to-eat food on the tray line; there was condensation between stacked plastic cups stored as clean; and labeling was inconsistent, making it difficult to determine when to discard leftover food.

Inspectors wroteBased on observations, interviews, and a review of the facility's policy titled Waste Disposal, the facility failed to ensure the dumpster area was maintained in a sanitary manner to prevent harborage of pests. This had the potential to affect 101 of 101 residents who resided at the facility. There was garbage on the ground around the dumpster and strewn along the edge of the parking area for three days of the survey. The dumpster door was open, and a bag, stuck in the lid, hung outside the dumpster.

Inspectors wroteBased on interviews, record review, and review of the Arbitration Agreement, the facility failed to ensure that the Arbitration Agreement presented to residents and resident representatives during admission included a clause that a mutually convenient venue for the Arbitration would be selected. This failure had the potential to affect 101 of 101 residents who had signed the Arbitration Agreement and future residents who might sign the agreement.

Inspectors wroteBased on record review, interviews, and the policy titled Medication Monitoring Medication Regimen Review and Reporting the facility failed to ensure the physician responded timely to the pharmacist's recommendations made during the monthly drug regimen reviews for four of five residents (R) (R2, R21, R77, and R63) reviewed for unnecessary medication.

Inspectors wroteBased on observations, interviews, record reviews, and a review of the facility's policy titled Test Tray, the facility failed to ensure the food was palatable for five out of 40 sampled residents (R) (R72, R31, R10, R14, and R30) and for residents who attended resident council meetings. Specifically, the food was not served at palatable temperatures; the food was bland; leftovers were routinely served in place of freshly prepared food; and condiments such as salt, pepper, sugar, and sugar substitute were not served in accordance with the menu.

Inspectors wroteBased on interviews, record review, and a review of the facility policy titled MDS Submissions, the facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment following the initiation of hospice services for one of two sampled residents (R) (R62) reviewed for hospice services.

Inspectors wroteBased on interviews, record review, a review of the facility policy titled MDS Submissions, and review of Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed at least once every three months for three of 52 residents (R) (R18, R36, and R65). This failure placed the residents at risk for unmet care needs due to the lack of a timely assessment to track any changes in the residents' status.

Inspectors wroteBased on interviews, record review, and a policy titled, MDS Assessment Coordinator, the facility failed to ensure that the Minimum Data Sets (MDS) assessments were accurate for two of 40 sampled residents (R)(R104 and R9) related to (1) not coding the presence of R104's pressure ulcer (to the sacrum) on a significant change MDS assessment; and (2) accurately coding the stage of the sacrum pressure ulcer on a subsequent quarterly MDS assessment for R9's diabetic foot ulcer.

Inspectors wroteBased on observation, interviews, record review, and review of the policies titled Care Plan Policy and Prevention of Pressure Ulcers, the facility failed to develop a person-centered care plan related to a diabetic foot ulcer for one of nine residents (R) (R9). This had the potential for the residents to have unmet care needs.

Inspectors wroteBased on observation, interviews, record review, and a review of the facility policy titled ADL Care - Bath (shower) Hygiene Care, the facility failed to provide showers to one of nine dependent residents (R) (R23) reviewed for activities of daily living (ADL) care. The failure to provide showers created the potential for poor hygiene and odor.

Inspectors wroteBased on observation, interviews, record review, and a review of the facility policy titled Bed Safety and Bed Rails, the facility failed to complete quarterly assessments for the continued use and safety of the bedrail for one of 40 sampled residents (R) (R22). This failure had the potential to affect all residents in the facility with bed rails and increase their risk of accidents.

Inspectors wroteBased on record review, interviews, and a policy titled Medication Ordering and Receiving from Pharmacy Provider, the facility failed to have antibiotic and pain medications available to administer as ordered for three of five sampled residents (R) (R2, R78, and R10).

Inspectors wroteBased on interviews, record review, and a review of the facility's policies titled Medication Ordering and Receiving from Pharmacy Provider, Administration of Drugs, and Medication Errors and Adverse Reactions, the facility failed to ensure that two of six sampled residents (R) (R2 and R72) were free from significant medication error.

Inspectors wroteBased on observations, record review, interview, and a review of the facility's policies titled Enhanced Barrier Precautions and Isolation - Categories of Transmission-Based Precautions, the facility failed to ensure that infection control practices was followed for two of 40 sampled residents (R) (R51 and R78) related to: (1) utilizing the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) for R51; and (2) having PPE available outside of a room for staff to don for R78.

Inspectors wroteBased on interviews and observations, the facility failed to ensure a safe and secure environment free from accident hazards by not keeping cabinets locked in the shower rooms on A and B Halls that contained cleaning supplies, toiletries, and disposable razors. This failure had the potential to harm two of 15 sampled residents (R) R13 and R14 that wandered the facility.

Inspectors wroteBased on observations, staff interview, and review of the facility policies titled, Dry Storage Area and Care of Storeroom, the facility failed to ensure food was properly stored, refrigerators were clean, floors were clean, freezers were without ice built up, food was not stored on the floor, and scoops were not stored inside the bins. The deficient practice had the potential to affect 91 of the 95 residents who consumed an oral diet.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the walk-in freezer was properly maintained. Specifically, the walk-in freezer had extensive ice buildup. This had the potential to affect 91 of the 95 residents who consumed an oral diet.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Influenza and Pneumococcal Immunizations, the facility failed to ensure five of five Residents (R)21, R83, R305, R89 and R17) and/or their representatives were education related to the risks and benefits of the influenza and pneumococcal vaccine.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to revise the Care Plan to include updated wound care for one of 31 residents (R)22 whose Care Plans were reviewed. The deficient practice had the potential to affect the needed wound care provided by the staff for R22.

Inspectors wroteBased on resident interview, staff interviews, and record review, the facility failed to ensure two of 31 residents (R) 25 and R22 had physician's orders followed. Specifically, the facility failed to ensure physician orders for notification of blood sugars (BS) were followed for R25 and a physician treatment order was followed for R22. The deficient practice had the potential for the residents to have unmet care needs.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to ensure routine maintenance was provided for three of three Residents (R)21, R89, and R93 reviewed for the safety of bedrails. The deficient practice had the potential to increase the risk of R21, R89, and R93 to sustain an injury by not conducting routine maintenance on bed equipment. Specifically, the facility failed to ensure residents requiring bedrail usage bedrails were routinely inspected and maintenance.

Inspectors wroteBased on resident interviews, staff interviews, record review, and review of the facility policies titled, Medication and Treatment Orders, Ordering and Receiving of Medications, and Administration of Medications, the facility failed to ensure two of five residents (Residents (R) 28 and 25) reviewed for medication administration out of a sample of 31 residents received medications as ordered by the physician. Specifically, the facility failed to contact the pharmacy to ensure medications were available for administration to the residents.

Inspectors wroteBased on observations, resident interview, staff interview, and review of the facility policy titled, Frequency of Meals, the facility failed to ensure one of one resident (R)22 received meals and assistance with meals in a timely manner.

Inspectors wroteBased on observations, staff interview, record review, and the review of the facility policies titled, Infection Control Guidelines for All Nursing Procedures and Handwashing/Hand Hygiene, the facility failed to ensure staff performed hand hygiene between glove changes while completing a dressing change to a feeding tube for two of two Residents (R)83 and R22 observed for a dressing change. The deficient practice had the potential to increase the risk of R83 and R22 to contract an infection as evidence by staff not performing hand hygiene when conducting dressing changes.