Bellway Health and Rehabilitation Center

Inspectors wroteBased on interviews, record review, the facility policies titled, Social Media Use, Personal Cell Phones, Resident Photographs, and Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, review of the facility's investigative files, and review of an Incident/Offense Report, the facility failed to: 1) ensure Resident Identifier (RI) #101 was free from mental and physical abuse perpetrated by staff at the facility. On 04/24/2024, Certified Nursing Assistant (CNA) #19 used her phone to record a video of CNA #18 physically and mentally abusing RI #101, who was in bed. In the recording CNA #18 taunted and laughed at RI #101 as she used aggressive force to pull up the resident's pants into the resident's perineum and buttocks. [...]

Inspectors wroteBased on observation, interview, the facility's 2024 Spring/Summer (S/S) Menu Diet Spreadsheets, the facility's production sheets, the facility's scoop/disher/dipper chart, and the facility's policies for The Dining Experience: Objectives, Menu Planning and Requirements, Menu Diet Spreadsheets/Portion Serving Communication Tool, Use of Production Sheets, and Menu Substitutions or Changes and Approval; the facility failed to provide pureed food items in the portions specified on the menu for supper on Tuesday, 07/09/2024 and for lunch on Thursday, 07/11/2024. The facility further failed to include cheese in the pureed entree as specified on the menu for supper on Tuesday, 07/09/2024 and did not receive approval from the Registered Dietitian (RD) to do so. [...]

Inspectors wroteBased on observations, interviews, and the facility policy titled, Safe and Homelike Environment, the facility failed to ensure two of six shower rooms on the South unit in the facility were free of soap build up on the walls and dark coloring on the floors. This affected Resident Identifier (RI) #108, and two of 11 shower rooms in the facility; however, the deficient practice had the potential to affect all 60 residents residing on the South unit who used the shower rooms. This deficient practice was cited as a result of the investigation of complaint/report number AL00048274. The facility further failed to ensure the left arm rest on RI #73's wheelchair (WC) was not torn. This affected RI #73, one of one resident observed with a torn WC armrest. Findings Include: Review of an undated facility policy titled, Safe and Homelike Environment, documented: Policy: [...]

Inspectors wroteBased on interviews, record review, group council meeting, and review of facility policy titled Resident and Family Grievances, the facility failed to ensure grievances filed by Resident Identifier (RI) #40 and RI #116 on 05/14/2024, 05/21/2024, and 05/30/2024 were resolved in a timely manner. Further, the facility failed to take prompt action to update complainants of progress towards a resolution. This deficient practice affected two of two residents sampled for grievances. Findings Include: A review of an undated policy titled Resident and Family Grievances revealed the following: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances . Definitions: Prompt efforts to resolve include . actively working toward resolution of that complaint/grievance . Procedure: . d. [...]

Inspectors wroteBased on observations, record review, interviews and review of a facility policy titled, Restraint Free Environment, the facility failed to ensure Resident Identifier (RI) #73's wheelchair (WC) seat belt was released during meal times on three of seven days of the survey 07/09/2024, 07/12/2024, and 07/15/2024. This deficient practice affected RI #73, one of one resident reviewed for the use of restraints.

Inspectors wroteBased on observations, review of the medical record, and staff interview, and review the facility policy titled Restorative nursing Programs, the facility failed to ensure a splinting device for Resident Identifier (RI) #64's hand was in place on 07/09/2024 and 07/11/2024 to prevent decreased Range of Motion (ROM). Findings Include: Review of an undated facility policy titled Restorative Nursing Programs documented: Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Definition: . This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. RI #64 was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis. [...]

Inspectors wroteBased on interviews, record review, review of a facility policy titled, Abuse, Neglect and Exploitation, and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #51 was free from misappropriation of funds from his/her personal funds. On 05/30/2024 RI #51 reported she was missing his/her money pouch and money. The money pouch and some of the money was later located in RI #123's bedside drawer. This deficient practice affected RI #51, one of 17 residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00048010. Findings Include: A review of the facility Abuse, Neglect, and, Exploitation Policy, , revealed: Policy: [...]

Inspectors wroteBased on observation, interviews, record review, review of Fundamentals of Nursing, Ninth Edition, [NAME] and Perry and review of a facility policy titled Administering Medications, the facility failed to ensure licensed staff remained with Resident Identifier (RI) #18 and observed to ensure accurate and complete medication administration. This was observed on 4/27/21 during the initial tour of the facility and affected one of one resident observed with medications at the bedside.

Inspectors wroteBased on observation, interviews, record review, review of the facility policy titled Isolation- Categories of Transmission-Based Precautions and review of the facility's COVID -19 Pandemic Plan, the facility failed to ensure staff donned Personal Protective Equipment (PPE) prior to entering Resident Identifier (RI) #206's room, a resident on isolation, when delivering the supper tray and assisting with tray set up. This was observed on 4/27/21 and affected one of three sampled residents on Transmission-Based Precautions.

Inspectors wroteBased on observations, interviews and a review of facility policy titled Food Storage, the facility failed to ensure: 1. cooked sausage patties and cheese slices were completely wrapped in the walk-in refrigerator and 2. items in a unit resident refrigerator were labeled and dated properly. The food items in the walk in refrigerator had the potential to affect 109 residents receiving meals from the kitchen and the unit resident refrigerator affected one of two unit resident refrigerators. Findings Include: A review of a facility policy titled Food Storage with no date, revealed POLICY : Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing . PROCEDURES .15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an Annual Minimum Data Set (MDS) assessment, dated 1/28/19, accurately reflected the stage of a pressure injury on admission for Resident Identifier (RI) #64. This affected RI #64, one of two resident's whose MDS was reviewed for accurate staging of pressure injury. Findings Include: RI #64 was admitted to the facility on [DATE]. RI #64's diagnoses included pressure ulcer of right hip unstageable, idiopathic scoliosis and spina bifida. A review of RI #64's Annual MDS, dated [DATE], indicated the resident's most recent admission date was 9/25/14. The MDS also revealed: . Section M . M0300 . C. 0 stage 3 pressure ulcers . D. 1 stage 4 pressure ulcer .1 stage 4 present upon admission . A record review of RI #64's Quarterly MDS dated [DATE] revealed . Section M . M0300 . C. 1 stage 3 pressure ulcers . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) did not clean bowel movement from Resident Identifier (RI) #61, then with the same soiled gloves place a clean pad, remove moisture barrier from the resident's bedside cabinet and apply moisture barrier to the resident. This was observed on 6/6/19 and affected RI #6, one of one resident's observed for incontinent care. Findings Include: RI #61 was admitted to the facility on [DATE]. Diagnoses included Morbid severe obesity due to excess calories and Lymphedema. A review of RI #61's Quarterly Minimal Data Set with an Assessment Reference Date of 4/17/19 revealed RI #61 required a one person extensive assistance with toileting needs. On 6/06/19 at 10:30 AM, the surveyor observed incontinent care for RI #61, performed by Employee Identifier (EI) #2, CNA. [...]