Benedictine Health Center Innsbruck

Inspectors wroteBased on interview and document review, the facility failed to ensure a voiced allegation of potential neglect of healthcare was immediately reported to the administrator, or designee, then reported to the State agency (SA) within 24 hours for 1 of 4 residents (R4) reviewed. R4 alleged nursing assistant (NA)-D had deliberately connected her to an empty oxygen tank and wouldn't fill it when told it was empty. R2 then experienced shortness of breath and had low oxygen saturation levels due to no oxygen in the tank.

Inspectors wroteBased on interview and document review, the facility failed to implement adequate nursing monitoring of a potential respiratory condition to help prevent complication (i.e., worsening) for 1 of 4 residents (R1) reviewed. R1 developed a semi-productive cough which required medication and diagnostic evaluation; however, no further ongoing vital sign or lung function monitoring was placed or recorded to ensure it resolved.

Inspectors wroteBased on interview and document review, the facility failed to ensure a stage III pressure ulcer (i.e., full-thickness skin loss) was accurately documented and adequately monitored for healing with weekly measurements and characteristic evaluations to promote continuity of care and reduce the risk of complication (i.e., worsening) for 1 of 4 residents (R1) reviewed.

Inspectors wroteBased on interview and documentation review the facility failed to notify the medical provider of a change of condition for 1 of 3 residents (R1) reviewed when R1 reported to the nurse she was not eating or drinking because it hurts my intestine and rectum, and she had loose stools, staff notified the provider three days later.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a dignified dining experience for 1 of 1 resident (R61).

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident's wishes for resuscitation were accurately documented in all areas of the medical record for 1 of 2 residents reviewed for inconsistent advanced directives.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement interventions for 1 of 1 resident (R47) who required alternate means of communication due to English as a second language.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 1 resident (R3) who required assistance with hygiene and was reviewed for activities of daily living (ADL). Findings Include:R3's comprehensive Minimum Date Set (MDS) dated [DATE], identified R3 had severe cognitive. Diagnoses included cerebral infarction (stroke) aphasia (difficulty communicating) and hemiplegia/hemiparesis (weakness/paralysis) of the left side. The MDS indicated R3 required maximal assistance with upper and lower body, and dependent on staff for all personal hygiene. R3's care plan revised on 2/5/26, identified ADL self- care deficient related to cerebral infarction. Interventions included maximal staff assistance with dressing, bathing and personal hygiene. The care plan directed that R3's facial hair was to be shaved daily. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure coordination of care through on going communication with hospice services for 1 of 1 residents (R10) reviewed for hospice had discrepancy in code status documentation identified and not resolved timely.

Inspectors wroteBased on observation, interview, and document review the facility failed to follow up on a 1 of 1 resident (R45) who glasses were broken.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R10) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen therapy was administered and maintained for 2 of 2 residents (R49, R9) reviewed for respiratory therapy.

Inspectors wroteBased on interview and document review, the facility failed to ensure medication orders were transcribed correctly (according to the physician orders) for 1 of 1 resident (R9) who was prescribed an antibiotic.

Inspectors wroteBased on interview and document review the facility failed to ensure medication was discontinued according to physician's orders for 1 of 1 resident (R9) receiving an antibiotic. Furthermore, the facility failed to ensure side effect monitoring was in place for 1 of 1 resident (R35) receiving an anticoagulant (blood thinner).

Inspectors wroteBased on record review and interviews the facility failed to update the care plan for 1 of 1 resident (R1) reviewed for communication.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper hand hygiene practices for 2 of 2 residents (R62, R59) observed during personal cares. In addition, the facility failed to ensure appropriate room assignment for 6 of 10 residents (R26,R23,R136,R74,R12,R11) reviewed for transmission based precautions (TBP). Also, the facility failed to ensure consistent and appropriate personal protective equipment (PPE) use for 5 of 10 residents (R11,R12,R73,R76, R59) reviewed for TBP and staff handling soiled laundry.

Inspectors wroteBased on observation and interview the facility failed to maintain dignity for 1 of 1 resident (R62) reviewed for dignity. R62's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting, was always incontinent of urine, and received a diuretic on routine basis. R62's care plan dated 4/25/25, indicated the potential for alteration of bowel and bladder related to a diagnosis of a neurogenic bladder and included an intervention of R62 requiring 2 person assistance to use the toilet upon rising in the morning, before and after each meal, bedtime, on night rounds, and as needed. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure personal privacy during activities of daily living (ADLs) was provided for 1 of 2 residents (R9) reviewed for privacy.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure resident specific target behavior monitoring for antipsychotic use and further failed to ensure a gradual dose reduction (GDR) of an antipsychotic for 1 of 4 residents reviewed (R9) for antipsychotic use.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide timely incontinence care for 1 of 1 resident (R62) reviewed for activities of daily living (ADL).

Inspectors wroteFeeding Tube R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 was cognitively intact, was dependent on staff for all activities of daily living (ADLs), and required a FT for nutrition. R37's diagnoses included dysphagia (difficulty swallowing) and nutritional deficiency, R37's care plan dated 5/13/24, indicated R37 had swallowing difficulty related to severe esophageal dysphagia and required nutrition provided using a feeding tube through a G-tube. R37's care plan instructed staff to check residual every four hours, flush G-tube with water before and after medications, maintain FT materials, not allow formula to hang longer than eight hours at room temperature, and change set up daily. R37's provider orders included the following: -Diet: NPO (nothing by mouth) except small sips of water-4/17/25 -Diet: [...]

Inspectors wroteR9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. Further, R9's vision was adequate with glasses. R9's care area assessment (CAA) dated 4/14/25, indicated R9 triggered for falls due to needing assist with cares, mobility, toileting due to multiple diagnoses and received Seroquel for psychotic disorder with delusions, and Zoloft for depression. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's Active Orders form indicated the following orders: [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow up on reported grievances in a timely manner for 1 of 2 residents (R9) reviewed for grievances.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the daily cleaning schedule was followed in the kitchen. During observation on 5/12/25 at 12:05 p.m., the kitchen floor was visibly soiled with dirt, there were multiple footprints, food spills, it was sticky, and there were copious amounts of food particles pushed down into the grout of the floor. During observation and interview on 5/14/25 at 10:37 a.m., the kitchen floor was visibly soiled with dirt, there were multiple footprints, food spills, it was sticky, and there were copious amounts of food particles pushed down into the grout of the floor. The director of dining services (DDS) verified the floor was dirty and stated kitchen staff were responsible for mopping the floor daily. [...]

Inspectors wroteBased on interview and document review, the facility failed to follow physician orders to provide a resident nothing by mouth for 1 of 5 residents (R1) reviewed for diet orders. This resulted in an immediate jeopardy (IJ) for R1 when he was provided with a pastry, orange juice and coffee by staff, and later became hypoxic and was sent to the hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 11/4/24 at 8:45 a.m. when nursing assistant (NA)-A provided R1 with a pastry, orange juice and coffee. The administrator and director of nursing (DON) were notified of the IJ on 11/8/24 at 2:48 p.m. The facility implemented corrective action on 11/5/24, prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly stored, labeled, and dated and disposed after expiration date. Furthermore, the facility failed to ensure the use of hair restraints. This deficient practice had the potential to affect all residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure vitals signs were taken as ordered for 1 of 3 residents (R77) reviewed for antipsychotic medication use and the facility failed to ensure resident's weights were monitored as ordered for 1 of 1 residents (R82) reviewed for nutrition. In addition, the facility failed to monitor skin alterations for 1 of 1 resident (R4) with facial bruising and failed to administer medications per doctor's order for 1 of 1 resident (R65) who repeatedly did not receive scheduled medications due to sleeping. Furthermore, the facility failed to ensure skin assessments were accurately documented for 3 of 3 residents (R90, R36, R88) reviewed for non-pressure skin altercations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure behaviors of potential wandering were comprehensively assessed for 3 of 3 residents (R15, R4, R21) and failed to assess for resident safety in the community for 1 of 1 resident (R15). The facility further failed to implement care planned interventions for 1 of 1 resident (R77) who wanders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (measures intended to prevent the spread of multidrug-resistant organisms ) were implemented for 2 of 3 residents (R83 and R24) observed for enhanced barrier precautions, and failed to ensure appropriate hand hygiene during assist with activities of daily living (ADLs) for 1 of 2 resident (R24). Last, the facility failed to ensure ice packs were stored separately from food storage in two unit refrigerators. This had the potential to impact the residents who resided on those units.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the dining room floor for 1 of 3 dining rooms was clean and sanitary.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive and individualized care plan was developed for 1 of 3 residents (R88) reviewed for psychotropic medication use.

Inspectors wroteBased on interview and record review the facility failed to provide routine showers for 1 of 1 residents (R90) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview, observation, and document review, the facility failed to implement a walking program as written to prevent potential decrease in mobility for 1 of 1 resident (R73) reviewed for walking programs.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 1 (R47) resident reviewed who had post-traumatic stress disorder (PTSD) symptoms.

Inspectors wroteBased on interview, and document review the facility failed to ensure assistance to a family member with determining mental capacity for 1 of 1 resident (R15) reviewed for social services.

Inspectors wroteBased on interview and document review the facility failed to ensure the provider's response to the initial medication review was followed and failed to ensure monitoring was in place for 1 of 3 residents (R88) reviewed for antipsychotic medication use.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (R88) who received antipsychotic medications had an appropriate indication and diagnoses for the medication. Furthermore, the facility failed to ensure staff were monitoring resident behaviors related to the antipsychotic medication and utilizing non-pharmacological approaches to ensure the antipsychotic medication was necessary.

Inspectors wroteBased on observation, interview and document review the facility failed to implement care planned interventions to prevent worsening of existing pressure ulcers for 1 of 3 residents (R4) reviewed with a pressure ulcer.

Inspectors wroteBased on observation, interview and document review the facility failed demonstrate root cause analysis, failed to perform ongoing analysis and failed to implement individualized interventions to reduce the risk for falls for 1 of 3 resident (R5) who sustained multiple falls since admission to the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 3 residents (R2) reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement the comprehensive care plan that included interventions to assist with eating for 1 of 3 residents (R2) reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide quarterly interdisciplinary team (IDT) care conferences for 1 of 5 residents (R6) reviewed for care plan timing and revision.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nail care and feeding assistance was provided for 1 of 3 residents (R2) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and document review, the facility failed follow safeguards in place to ensure residents received the correct medications for 1 of 3 residents (R4) reviewed for medication error.