Best Care Health and Rehabilitation

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed record review, staff interviews, policy review, and review of hospital documentation, the facility failed to ensure a resident received adequate assistance during a transfer to prevent an avoidable fall. This resulted in Actual Harm to Resident #95 when on 12/21/25 she fell on to the floor in the bathroom while being assisted with toileting by one staff member. Resident #95 sustained a fracture of the right femoral head and the left distal femur. This affected one (Resident #95) of three residents reviewed for falls. The facility census was 90.

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to notify the Ombudsman of discharge. This affected three Residents (23, #68 and #120) of four reviewed for discharge. The facility census was 79.

Inspectors wroteBased on observation, staff interview and medical record review the facility failed to ensure physician orders were in place for Resident #68 foley catheter. This affected one (Resident #68) of one resident resident reviewed for foley catheters. The facility census was 79.

Inspectors wroteBased on medical record review , interview, and facility policy review, the facility failed to ensure medications on admission were received from pharmacy and administered to the residents timely. This affected three Residents (#42, #68 and #120) of five residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on review of the Resident Council meeting minutes, staff interview, and resident interview, the facility failed to ensure concerns discussed during the meetings were adequately addressed. This had the potential to affect five facility-identified residents ( #10, #27, #44, #47, #65) who consistently attended the Resident Council meetings. The facility census was 66 residents.

Inspectors wroteBased on observation, staff interview and review of the facility policy, the facility failed to ensure medication carts on the front hall were locked and secured. This had the potential to affect seven facility-identified cognitively impaired and independently mobile residents of 22 residents residing on the front hall. The facility census was 66 residents.

Inspectors wroteBased on record review, observation, resident interview, ombudsman interview, and staff interview, the facility failed to ensure residents were not discharged without a justified and documented reason. This affected one (Resident #20) of three residents reviewed for discharge rights. The facility census was 66 residents.

Inspectors wroteBased on medical record review and the staff interview the facility failed to update resident Preadmission Screening and Resident Reviews (PASARRs) for residents with new diagnoses and/or treatment with psychotropic medications. This affected two (Residents #39 and #52) of four residents reviewed for PASARR completion. The facility census was 66 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide regular care plan conferences to residents and their representatives. This affected one (Resident #20) of three residents reviewed for care conferences and care planning. The facility census was 66 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure skin alterations were adequately monitored and treated. This affected one (Residents #1) of 23 residents sampled. The facility census was 66 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure adequate care and services for residents requiring oxygen. This affected one (Resident #8) of 20 residents with orders for oxygen therapy. The facility census was 66.

Inspectors wroteBased on medical record review, observation, resident interview, staff interviews, and review of facility policy, the facility failed to ensure adequate monitoring of a resident pain. This affected one (Resident #45) of four residents reviewed for pain management. The facility census was 66 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident with post-traumatic stress disorder (PTSD) were appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one (Resident #5) of one resident identified by the facility as having PTSD. The facility census was 66 residents.

Inspectors wroteBased on medical record review, staff interview, review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #228) of 13 facility-identified newly admitted residents and one (Resident #45) of five residents reviewed for unnecessary medications. The facility census was 66 residents.

Inspectors wroteBased on record review, staff interview, review of online resources per the Centers for Disease Control (CDC) regarding pneumococcal vaccinations, and review of facility policy, the facility failed to ensure residents were offered and received up to date pneumococcal vaccinations. This affected two (Residents #3 and #43) of five residents reviewed for vaccinations. The facility census was 66 residents.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure only authorized personnel had access to the medication storage room. This had the potential to affect 80 of 80 residents residing in the facility.

Inspectors wroteBased on observations, staff interview, resident interview, and policy review, the facility failed to ensure residents had access to their personal funds during times the business office was not open (evenings and weekends). The facility handled funds for 47 of 80 residents. This had the potential to affect any resident whose funds were handled by the facility.

Inspectors wroteBased on observations, staff interview, resident interview, medical record review, and grievance review, the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This affected 24 of 26 residents on Station 1 who were incontinent of bowel and/or bladder (Residents #9, #10, #11, #20, #21, #29, #32, #33, #38, #42, #43, #45, #47, #49, #51, #52, #53, #60, #65, #67, #72, #74, #76, and #80). The facility census was 80.

Inspectors wroteBased on observations, record review, staff interview, resident interview, review of a grievance form, review of resident council meeting minutes, and review of staffing schedules and time sheets, the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected 24 of 26 residents on Station 1 who were incontinent of bowel and/or bladder (Residents #9, #10, #11, #20, #21, #29, #32, #33, #38, #42, #43, #45, #47, #49, #51, #52, #53, #60, #65, #67, #72, #74, #76, and #80) and had the potential to affect all 80 residents residing in the facility.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to provide pharmaceutical services to meet the needs of each resident. This affected 20 of 27 residents who received narcotic medications (Residents #2, #4, #12, #14, #15, #20, #22, #24, #25, #33, #45, #51, #53, #55, #59, #61, #64, #67, #72, and #76) and one of three closed records reviewed (Resident #85). The facility census was 80.

Inspectors wroteBased on medical record review, observations, staff interview, and policy review, the facility failed to ensure medical records were accurately documented. This affected three of 12 sampled residents (Residents #54, #64, and #75). The facility census was 80.

Inspectors wroteBased on observations, medical record review, staff interview, and policy review, the facility failed to ensure a gastrostomy tube was checked for placement prior to the administration of fluids and medication. This affected one of three residents observed for medication administration (Resident #54). The facility census was 80.

Inspectors wroteBased on staff interview, medical record review, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two of 80 residents residing in the facility (Residents #64 and #75).

Inspectors wroteBased on state/federal economic stimulus and Medicaid guideline review, record review, financial record review and interview the facility failed to ensure each resident who received Medicaid and/or their financial representative were notified when the amount in the resident's personal funds account reached $200.00 less than the SSI resource limit as required. This affected four residents (#57, #74, #34 and #37) of 65 residents whose personal fund records were reviewed. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident who utilized Medicaid insurance may not keep more than $2000.00 in a trust account. Also, the same guidelines revealed COVID-19 stimulus checks (three total) did not count as monthly income; so they would not affect a resident's medical coverage. [...]

Inspectors wrote3. Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, non-pressure chronic ulcer of the right heel and mid-foot, muscle weakness, cognitive communication deficit, peripheral vascular disease, non-pressure chronic ulcer of left heel and mid-foot, type two diabetes mellitus and chronic systolic heart failure. Review of documented weights revealed on [DATE] the resident weighed 143.5 pounds, on 07/11 the resident weighed 140.8 pounds, on [DATE] the resident weighed 136.8 pounds, and on [DATE] the resident weighed 136.6 pounds. Review of the care plan, dated [DATE] revealed the resident had the potential for nutritional problems. [...]

Inspectors wroteBased on observation, record review, interview and facility policy and procedure review the facility failed to maintain Resident #288's privacy when the resident was not properly dressed resulting in the resident being exposed to others in the hallway from in the room. This affected one resident (#288) of one resident reviewed for dignity. Findings Include: Review of Resident #288's medical record revealed an admission date of 07/22/22 with the admitting diagnoses of COVID-19, chronic kidney disease, congestive heart failure, atrial fibrillation and presence of pacemaker. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/29/22 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for Resident #71 related to the use of anti-depressant medications and for Resident #288 related to an ostomy appliance. This affected two residents (#71 and #288) of 26 residents whose MDS 3.0 assessments were reviewed. Findings Include: 1. Record review revealed Resident #71 was admitted to the facility on [DATE] with a diagnosis of depression. Review of the physician's orders revealed an order, dated 07/12/22 for the anti-depressant medication, Lexapro 20 milligrams (mg) to be administered once daily due to a diagnosis of depression. Review of the care plan, dated 07/12/22 revealed the resident was receiving anti-depressant medication. Interventions included to observe for side effects, consult the pharmacist as needed and provide medication as ordered. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure baseline care planning was comprehensive and included information related to activities of daily living and/or wound care. This affected two residents (#52 and #62) of 26 residents whose assessments and care plans were reviewed. Findings Include: 1. Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including muscle weakness, atrial fibrillation, type two diabetes and cognitive communication deficit. Review of the facility baseline care plan summary, dated 07/02/22 revealed the plan failed to include information regarding the level of assistance the resident required with activities of daily living (ADL). [...]

Inspectors wroteBased on closed record review and interview the facility failed to ensure a complete and accurate discharge summary was provided for Resident #13 at the time of discharge. This affected one resident (#13) of three residents reviewed for transfer/discharge. Findings Include: Review of Resident #13's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, difficult ambulation, dysphagia, cognitive communication deficit, hypertension, hypothyroidism, renal dialysis, urinary tract infection, atrial fibrillation, atherosclerosis, insomnia and glaucoma. Resident #13 was discharged home on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/20/22 revealed the resident had no cognitive impairments. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents who required staff assistance with activities of daily living received adequate and timely assistance with personal care to maintain proper hygiene/grooming/nail care. This affected three residents (#62, #75 and #288) of six residents reviewed for activities of daily living. Findings Include: 1. Review of Resident #75's medical record revealed an admission date of 07/13/20 with the admitting diagnoses of trochanteric bursitis of left hip, generalized muscle weakness, Alzheimer's disease, dementia with behavioral disturbances, low back pain, hypertension, thoracic aortic aneurysm and hearing loss. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs of Resident #74. This affected one resident (#74) of three residents reviewed for activities. Findings Include: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including anxiety, muscle weakness, and cognitive communication deficit. Review of the care plan, revised 11/05/19 revealed the resident enjoyed activities including board games, trivia, bluegrass music and watching animal planet. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/20/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 (out of 15). [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure adequate care and services were provided to residents receiving hospice care, care of non-pressure wounds and/or for diabetic blood sugar monitoring. This affected one resident (#61) of one resident reviewed for Hospice services, one resident (#62) of two residents reviewed for skin conditions and two residents (#62 and #71) of five residents reviewed for unnecessary medication use. Findings Include: 1. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, cognitive communication deficit and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22 revealed the resident was assessed to have moderately impaired cognition. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive pressure ulcer prevention and management program to ensure pressure ulcers were timely and accurately assessed, to ensure treatments were initiated timely and provided to promote healing of pressure ulcers and to prevent potential infection. This affected two residents (#283 and #288) of three residents reviewed for pressure ulcers. Findings Include: 1. Review of Resident #283's medical record revealed an initial admission date of 07/22/22 with the admitting diagnoses of chronic congestive heart failure, pressure ulcer of sacral region, chronic kidney disease, malaise, diabetes mellitus, non-pressure chronic ulcer to right lower leg and left lower leg, varicose veins of right and left lower leg. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to identify, obtain a physician's order and document the care of Resident #288's colostomy. This affected one resident (#288) of one resident reviewed for bowel and bladder. Findings Include: Review of Resident #288's medical record revealed an admission date of 07/22/22 with the admitting diagnoses of COVID-19, chronic kidney disease, congestive heart failure, atrial fibrillation and presence of pacemaker. Review of the resident's clinical health status evaluation, dated 07/23/22 revealed the resident was admitted to the facility with an ostomy. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure meals provided to Resident #292 accommodated the resident's preferences and were nutritionally adequate. This affected one resident (#292) of seven residents reviewed for nutrition. Findings Include: Review of Resident 292's medical record revealed an initial admission date of 07/20/22 with the admitting diagnoses of fracture of lower end of right radius, difficulty walking, unsteadiness on feet, dementia, depression and insomnia. Review of the clinical health status evaluation revealed no documented diet preferences for the resident. [...]

Inspectors wroteBased on observation, medical record review, and interview the facility failed to accurately code residents Minimum Data Set Assessment (MDS) assessments when dialysis was not coded for Resident #13, discharge status was inaccurate for Resident #76, anticoagulant use was miscoded for Resident #2 and Resident #50, and hospice was miscoded for Resident #2. This affected four residents (Resident #13, #76, #2, and #50) out of 22 residents assessed for MDS accuracy. The facility census was 86.

Inspectors wroteBased on record review and staff interview the facility failed to refer a resident with a new diagnosis of schizophrenia for a pre-admission screening and resident review (PASARR). This affected one (Resident #35) of one resident reviewed for PASARR. The facility census was 86.

Inspectors wroteBased on observation, resident and staff interview, and record review the facility failed to develop comprehensive care plans for Resident #32 for anti-anxiety medication use, Resident #2 for oxygen use, and Resident #41 for dental. This affected three (Resident #2, #32 and #41) of 22 residents reviewed for care plans. The facility census was 86.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to update and revise residents care plans. This affected one resident ( Resident #13) out of 22 residents assessed for careplan accuracy when Resident #13's care plan did not reflect she had glasses and her loop recorder was not careplanned. The facility census was 86.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to adequately and accurately assess diabetic foot ulcers and provide geri sleeves per plan of care for Resident #13 and failed to provide ordered ACE bandages in place for Resident #35. This affected two residents (Resident #13 and Resident #35) out of five residents reviewed for care and treatment of skin areas. The facility census was 86.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to provide Resident #13 with ordered assistive devices (glasses) daily. This affected one resident ( Resident #13) out of three residents reviewed for ancillaries. The facility census was 86.

Inspectors wroteBased on record review, observation and interviews the facility failed to appropriately date and label oxygen tubing for a resident on continuous oxygen. This affected one resident (Resident #5) of two residents reviewed for respiratory care.

Inspectors wroteBased on observation , resident interview, record review, and staff interview the facility failed to ensure pain management was provided to residents consistent with professional standards of practice when they failed to monitor and record pain levels for a resident who was coded for pain on the Minimum Data Set assessment and who had a decrease in her pain medication. This affected one (Resident #72) of one resident reviewed for pain. The facility census was 86.