Bella Vita Health and Rehabilitation Center

Inspectors wroteBased on clinical record reviews, staff and resident interviews, review of facility documentation, and policy and procedures, the facility failed to ensure one (#1) out of three sampled residents was free from a significant medication error. The deficient practice could result in resident discomfort or jeopardize the resident's health and safety. Findings Include:Resident #1 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included anterior dislocation of left humerus,(primary) hypertension, cirrhosis of liver, chronic viral hepatitis C, iron deficiency anemia, schizophrenia, gastro-esophageal reflux disease, anxiety disorder, Waldenstrom macroglobulinemia, aphasia, hearing loss, and depression. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 was cognitively intact. [...]

Inspectors wroteBased on staff and residents interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#2) right to be free from verbal abuse from a staff member for one of eleven sampled residents. The deficient practice could result in psychosocial harm to the resident.-

Inspectors wroteBased on clinical record review, hospital discharge documentation review, staff interviews, and review of facility policies and procedures, the facility failed to ensure physician-ordered services were provided in accordance with professional standards of practice for one (#16) of three sampled residents by failing to implement and coordinate physician-directed oncology follow-up appointments identified on the hospital discharge plan. The deficient practice had the potential to result in delayed evaluation, diagnosis, monitoring, and treatment of the resident's medical condition.

Inspectors wroteBased on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that one resident's (#911) injury of unknown origin was reported to the state agency. The deficient practice could result in injury of unknown origin not being reviewed for potential abuse.

Inspectors wroteBased on closed record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure that the receiving facility was provided the required documentation pertaining to one resident's (#911) transfer/discharge. The deficient practice could lead to the receiving facility not having the appropriate information regarding the resident's medical status and cause a delay in treatment/care.

Inspectors wroteBased on observation, interviews, facility documentation, policy review, and the State Agency complaint tracking system, the facility failed to ensure that one resident (#1) was not neglected by failing to assess and meet their basic needs to prevent the development of a Stage 3 pressure ulcer and Deep Tissue Injury (DTI). The deficient practice could result in the residents' development of pressure ulcers and deep tissue injuries.

Inspectors wroteBased on clinical record review, staff and resident/resident representative interviews, the facility failed to ensure that the resident and resident ' s representatives were a part of the discharge/transfer process for 4 of 5 sampled residents (#21, #32, #16 and #14).

Inspectors wroteBased on clinical record review, staff and resident/resident representative interviews, the facility failed to ensure that residents and/or the resident's representative (RR) were notified in writing of transfer to another facility for 2 of 5 sampled residents (#21, and #14). Failure of notification had the potential to affect the resident and their RR by not having clear knowledge of where and why the resident was transferred.

Inspectors wroteBased on observations, staff and resident/resident representative interviews, clinical record and policy review the facility failed to ensure that two resident 's (#214 and #525) were free from abuse. The deficient practice may result in physical and/or psychosocial harm to the residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the Ombudsman of transfer/discharge for one resident (#163). Failure to notify Ombudsman of transfers/discharges may result in residents being discharged against their will.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#320) was provided assistance with showering and dressing. This deficient practice could result in residents not being provided appropriate hygiene care and services.

Inspectors wroteBased on observation, clinical record review, interviews, and policy review, the facility failed to ensure that a blood pressure medication was administered within ordered parameters for one resident (# 60). Findings Include: Resident # 60 was re-admitted to the facility on [DATE] with diagnoses that included dependence on hemodialysis, hypotension, hypothyroidism, muscle weakness, and unspecified issues of the musculoskeletal system. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The care plan for hypotension-initiated January 3, 2024, revealed for staff to monitor, and record vital signs, and to report any significant abnormalities to the physician (MD). [...]

Inspectors wroteBased on observations, staff and resident interviews, clinical record and policy review the facility failed to ensure enhanced barrier precaution orders were implemented for two residents (#157 and #60); proper infection control practices were implemented during the laundry process; and that, infection prevention and personal protective equipment were utilized as ordered for one resident during medication administration. The deficient practice could result in a spread of preventable illness to residents and staff. Findings Include: -Regarding Resident #157 Resident #157 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left side, morbid obesity, and dysphagia. [...]

Inspectors wroteBased on record review, staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#11) was free from abuse from a staff member. This deficient practice could result in the physical and/or mental harm of a resident.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of one resident (#107) to be free from abuse by a resident. The deficient practice could result in residents subjected to further abuse.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure that risks and benefits of psychotropic medications were explained to 3 residents (#111, #37, and #548) and/or their representatives prior to receiving the medications. The sample size was 5 residents. The deficient practice could result in residents and/or their representatives not being informed of the risks and benefits of psychotropic medications.

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) documentation was complete, accurate, and available for three residents (#12, #100, and #3). The sample size was 4 residents. The deficient practice could result in residents not receiving specialized services that they require.

Inspectors wroteBased on clinical record reviews, facility documentation, observations, staff interviews, and facility policies, the facility failed to ensure 2 residents (#24 and #19) received consistent showers and failed to ensure one resident (#548) received meal assistance. The sample size was 7 residents. The deficient practice could result in resident's needs not being met.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#548) was treated with respect and dignity. The census was 166. The deficient practice could negatively impact the psychosocial well-being of the residents. Findings Include: Resident #548 was admitted on [DATE] with diagnoses that included COVID-19, unspecified psychosis, need for assistance with personal care, unspecified dementia without behavioral disturbance and abnormal weight loss. The baseline care plan dated January 27, 2022 indicated the resident had a potential nutritional problem related to COVID, anxiety, depression, coronary artery disease, lung cancer, psychosis, and weakness. The dietary orders revealed an order dated January 28, 2022 for a regular diet, mechanical soft texture, with thin liquids consistency. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, policy and procedures, the facility failed to ensure the Ombudsman was notified regarding a transfer for one resident (#75). The deficient practice could result in residents not protected from inappropriate discharge.

Inspectors wroteBased on personnel file review, staff interviews, facility policy and procedure, the facility failed to ensure two temporary nurse aides (#151 & #47) were fully trained to provide care to residents. The deficient standard could lead to care provided to residents does not meet their needs safely and in a manner that promotes residents' rights, physical, mental and psychosocial well-being.

Inspectors wroteBased on clinical record review, staff interview and facility policy and procedure review and the National Institute of Mental Health and the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders - 5th Edition), the facility failed to ensure there were adequate indications for the use of an antipsychotic medication for one resident (#148). The deficient practice could result in residents receiving an unnecessary psychotropic medication.

Inspectors wroteBased on an observation, staff interviews, and policy and procedures, the facility failed to ensure proper infection control measures related to use of Personal Protective Equipment (PPE) were followed by one staff member (staff #151). The deficient practice could result in the spread of infection.