Bent County Healthcare Center

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, entrance to the dish room and the dish receiving room were identified and corrected in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#29, #32, #35 and #36) out of 14 received activities to meet the needs and interests of the residents out of 20 sample residents. Specifically, the facility failed to: -Provide person-centered activities for Resident #29, Resident #32, Resident #35 and Resident #36; and, -Ensure Resident #32 and Resident #36 were assisted to a group activity when they requested to attend.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#36) out of one of 20 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure Resident #36 received nectar thick liquids per physician's orders.

Inspectors wroteBased on observations, record review and interviews the facility failed to maintain an effective pest control program so the facility was free from pests and cockroaches, in one of one kitchen and one of two dining rooms. Specifically, the facility failed to: -Ensure an effective pest control program that eliminated the presence of live and dead cockroaches in the kitchen and dining room, food preparation area, storage area, serving and eating areas; -Ensure dead and decaying roaches were removed from the dining room lower cupboard space; and, -Ensure heavily occupied sticky pest traps, containing a large amount of trapped dead and decaying cockroaches were removed timely and when the traps were full.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#105) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. During the 4/28/23 visit, the surgeon removed the sutures and staples from the surgical site on both sides of the right ankle. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The order also noted to keep the boot on except for baths. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure for one (#1) of two residents reviewed for pressure injuries received care consistent with professional standards of practice. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The orders also noted to keep the boot on except for baths. The resident had complaints of pain to the right lower extremity on 5/11/23. The nurse assessed the area and found the resident had developed an unstageable pressure injury to the right heel. The facility had not assessed or monitored the ankle for 12 days. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on a hose in the biohazard room sink, west shower room and the south shower room, increasing the risk of contamination to the facility's main water supply.

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 13 of 32 resident rooms in three hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure safe water temperatures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for four of five certified nurse aides (CNAs), one of one licensed practical nurses (LPNs) and four of four registered nurses (RNs). Specifically, the facility: -Failed to complete competencies as identified in the facility assessment for CNAs #1, #2, #4, and #5; -Failed to complete competencies as identified in the facility assessment for LPN #1; and -Failed to complete competencies as identified in the facility assessment for RNs #1, #3, #4, and #5.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for four of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #1, CNA #2, CNA #4 and CNA #5.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Food was stored and labeled properly.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies.

Inspectors wroteBased on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#8) of four residents reviewed for PASRR out of 24 sampled residents. Specifically, the facility failed to notify the State Mental Health Agency when recommendations had not been met for Resident #8.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for two (#12 and #24) of five residents reviewed out of 24 sample residents. Specifically the failed failed to: -Obtain a level I screening for Resident #12 who suffered from mental illness (MI) prior to admission so a level II evaluation and determination could be completed by the State Mental Health Agency; -Notify the State Mental Health Agency Resident #24 had exceeded the 30 day provisional preadmission screening and resident review (PASRR) period; and -Submit a new PASRR to the State Mental Health Agency for Resident #24 to determine if a level II evaluation was needed.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#27 and #28) of two residents reviewed for supplemental oxygen use out of 24 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #27 and 28.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were provided medically related social services to attain and maintain the highest practicable mental and psychosocial wellbeing for three (#24, #12, and #9) of five residents reviewed out of 24 sample residents. Specifically, the facility failed to ensure: -Social services was providing and arranging needed mental and psychosocial counseling services for Residents #24 and #9; -Social services was meeting the needs of residents who were having difficulty with change, loss, and adjustment for Residents #24, #12 and #9; and -Social services was meeting the need for emotional support for residents suffering from suicidal ideations and changes in mental health symptoms for Residents #24 and #12.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#39) of five residents reviewed for unnecessary medications. Specifically, the facility failed to ensure the ordered antibiotic was effective to treat the resident.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#24, #12, and #9) of five residents reviewed were free from unnecessary psychotropic medications out of 24 sample residents. Specifically, the facility failed to monitor targeted behaviors and provide non-pharmacological interventions for psychotropic medications for Residents #24, #12 and #9.

Inspectors wroteBased on observations and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, the facility failed to ensure menu items were not omitted from the lunch menu service for all residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure immediate physician notification for one (#15) of five residents reviewed out of 25 sample residents. Specifically, the facility failed to notify the physician of Resident #15's high blood sugars/glucose levels that were out of physician ordered parameters.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected residents' status for three (#20, #26 and #32) of 16 out of 25 sample residents. Specifically, the facility failed to appropriately assess, according to the Resident Assessment Instrument (RAI): -Behavior-Psychosis for Resident #20; -Medications for Resident #26; and, -Restraints-Alarms for Resident #32.

Inspectors wroteBased on record review, observations and interviews the facility failed to develop and implement a comprehensive, resident centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (#26) of 16 out of 25 sample residents. Specifically, the facility did not ensure Resident #26's comprehensive care plans were developed and included appropriate preventative interventions and treatments for wounds on her buttocks.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#20) of three residents reviewed for falls out of 25 sample residents. Specifically, the facility failed to comprehensively review, implement effective interventions and update the resident's care plans after multiple falls for Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#41) of three residents reviewed for oxygen therapy out of 25 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #41.