Bhm Carrollton Opco LLC

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect one of three sampled residents' (R) (R1) rights to be free from physical and verbal abuse by a staff member when Certified Nursing Assistant (CNA) NN struck R1 while providing care.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Food Safety Requirements, the facility failed to store, handle, and serve food in a safe and sanitary manner by failing to: ensure expired food items were discarded; ensure food items were properly labeled and dated; properly store raw meat to prevent cross-contamination; maintain food storage areas in a clean condition; properly store food off the floor; ensure equipment and surfaces were maintained in a sanitary condition; and ensure meal tray carts were covered during transport. This deficient practice had the potential to affect all 94 residents who receive food orally by placing them at increased risk for foodborne illness, contamination, and infection.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy titled Routine Cleaning and Disinfection, the facility failed to maintain a safe, clean, and comfortable home-like environment related to dusty grayish buildup on packaged terminal air conditioner (PTAC) units in one of four halls (300 Hall).

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Consulting Physician/Practitioner Orders and Provision of Quality of Care, the facility failed to provide treatment and care in accordance with professional standards of practice for two of 48 sampled resdients (R) (R2 and R48) related to ensuring that physician orders were in place to provide standard of care concerning: 1) catheter care, in that a physician order was not in place for indwelling Foley catheter and catheter care for R2 resulting in approximately 85 days of catheter care provided without a corresponding physician order; and 2) documentation and assessment of bowel movements and risk for bowel impaction for R48 resulting in the resident to be hospitalized for a 24-hour period for nausea and vomiting that was caused by a bowel impaction. [...]

Inspectors wroteBased on observation, record review, staff interviews, and the facility policy titled Restorative Nursing Program, the facility failed to provide restorative services for one of three sampled residents (R) (R86) related to splinting and range of motion (ROM) services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate safety interventions were implemented and followed for one of 48 sampled residents (R) (R11) by failure to ensure the resident wore a smoking apron while smoking. This deficient practice placed the resident at risk for burns and other accident hazards related to smoking injuries.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policies titled Oxygen Administration and Oxygen Concentrator, the facility failed to ensure that three of 11 sampled residents (R) (R45, R104, and R56) received respiratory care as ordered related to oxygen therapy and a Bilevel Positive Airway Pressure (BIPAP) machine.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure the medication rate was less than 5 percent (%) related to four errors with thirty-two opportunities. The medication error rate was 12.5%.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Hand Hygiene, the facility failed to perform hand hygiene when performing resident care, including Foley catheter care and wound care, for one of 48 sampled residents (R) (R2). This deficient practice had the potential to cause the spread of infection to other areas of the residents' bodies and infection to staff.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, the facility failed to protect one of 14 sampled residents (R) (R3) right to be free from sexual abuse from R5. This deficient practice created the potential for R3 and other residents to experience further potential abuse.

Inspectors wroteBased on record review and interviews, the facility failed to act upon a change of condition for one of 28 sampled residents (R) (263) related to low blood sugar, which resulted in being transferred to the hospital for treatment. This failure to provide quick intervention led to harm being identified on 12/29/2023, when R263's blood sugar went so low, to the point where the resident was unresponsive and slow to respond to the emergency use of Glucagon intramuscular when administered at the facility. R263 had to be transferred to the emergency room (ER).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the kitchen's two convection ovens, deep fat fryer, steamer, storage shelves, large manual can opener, and the main dining room's ice machine and microwave oven clean and sanitized. Additionally, the dietary staff failed to label, date, and/or cover food and beverages stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses, which could affect 101 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the soiled and clean sides of the laundry room were in good repair. Specifically, the facility failed to repair a gap under the exterior door that opens into the soiled laundry area; failed to repair broken wallboard with exposed insulation; failed to clean the air vents in the soiled side of the laundry that had debris build up; the doorless opening between the sorting area and the room with the washing machines was trimmed with unfinished molding, rendering the surface uncleanable; the floor where the washing machine was located had heavy debris build up; reusable rubber gloves were on the floor in the drying area; and the floor (standing) fan had heavy debris build-up on the fan grate. This deficient practice had the potential for the clean linen for all residents to be contaminated.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to serve food that was palatable and hot to four of seven residents (R) (R22, R77, R83, and R105) reviewed.

Inspectors wroteBased on record review, staff interview, and a review of the facility policy titled Resident Self-Administration of Medication, the facility failed to ensure that one of 28 sampled residents (R) (R89) was assessed for self-administration of medications before medications were left at the bedside. This failure had the potential for the residents to overmedicate themselves or for medications to be accessed by other residents.

Inspectors wroteBased on record review and interviews, the facility failed to notify one of 28 sampled resident's (R) (R89) responsible party (RP) of a new medication order before the administration of the medication to the resident. This failure had the potential for R89 to be administered with medication that the RP may not want the resident to receive.

Inspectors wroteBased on record review, interviews, and review of facility policy titled Abuse Prevention Program, the facility failed to ensure one of three sampled residents (R) (R33) reviewed for abuse was free from abuse. This failure had the potential for psychosocial impairment from being physically abused by another resident.

Inspectors wroteBased on record review, interviews, and a review of the facility policies titled Abuse, Neglect and Exploitation and Abuse Prevention Program, the facility failed to ensure allegations of abuse were reported to the facility's abuse coordinator/administrator promptly for one of four residents (R) (R62) with allegations of abuse. The facility failed to notify the State Agency (SA) promptly. This deficient practice placed the resident at risk for uninvestigated abuse allegations.

Inspectors wroteBased on record review, staff interview, and a review of the facility's policy titled Care Plans, the facility failed to develop and implement a comprehensive care plan for two of 28 sampled residents (R) (R44 and R263). This failure had the potential for R44 to not receive the appropriate treatment needed, and R263 did not have the newly identified pressure ulcer treatment ordered to prevent the area from becoming larger.

Inspectors wroteBased on the record review and interviews, the facility failed to investigate a fall for one of three residents (R) (R70) reviewed for falls. This failure had the potential for the fall not to be investigated thoroughly, and allowed R70 to experience another fall.

Inspectors wroteBased on interviews, record review, and a review of the facility policy titled End-Stage Renal Disease, Care of a Resident with, the facility failed to complete a Dialysis Communication Form for one of 28 sampled residents (R) (R77) to ensure effective communication regarding the provision of care and medication administration for dialysis. The failure had the potential for R77 to have unmet care needs and complications with her dialysis treatments.

Inspectors wroteBased on record review, interviews, and a review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, the facility failed to implement policies and procedures to monitor response to psychoactive medications, including specific behaviors to monitor, non-pharmacological interventions, and response to the interventions for two of five residents (R) (R62 and R66). The facility's failure to identify specific targeted behaviors and non-pharmacological interventions to address the behaviors placed the R62 and R66 at risk of inappropriate psychoactive medication use.

Inspectors wroteBased on observation, interview, record review, and review of facility policy titled Administering Medications,, the facility failed to ensure a medication error rate below five percent. During medication administration, two medication errors for one of 25 residents (R) (R5) opportunities resulted in a medication error rate of eight percent (%). These failures had the potential to increase or decrease the effectiveness of these medications.

Inspectors wroteBased on observation, interview, record review, facility menu review, and facility policy review, the facility failed to ensure that menus were followed as planned for one (R) (R105) of seven sampled residents reviewed for food in a total sample of 28 residents. This failure had the potential to cause nutritional needs to go unmet for 110 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide a bedtime snack each night for three of three diabetic residents (R) (R76, R77, and R83). This failure had the potential to cause unmet nutritional needs for residents who received meals and snacks from the facility's kitchen.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to ensure residents' room were in good repair in five of 70 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) observed for a safe, homelike environment. Specifically, a black substance was observed next to the air conditioning unit next to bed C in room [ROOM NUMBER], the bathroom door would not close in room [ROOM NUMBER], a large hole was observed in room [ROOM NUMBER]'s bathroom, the drywall was damaged with a hole in room [ROOM NUMBER]'s bathroom, and the caulking was dirty and needed replacement and drywall patching was left unpainted in room [ROOM NUMBER]'s bathroom and next to bed C.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Resident Trust Fund, the facility failed to allow two of 74 residents (R) (R74 and R59) with personal funds accounts to take out an amount greater than $20.00 a day. This deficient practice had the potential to not allow a resident to make purchases greater than $20.00 a day affecting 74 residents with personal funds.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, CPAP/BIPAP Support, the facility failed to ensure appropriate respiratory services for one of two residents (R) (R59) reviewed for respiratory services. Specifically, the facility failed to ensure clean filters were in the Continuous Positive Airway Pressure (CPAP) machine. The deficient practice had the potential for respiratory infections for R59.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Handwashing/Hand Hygiene, the facility failed to follow the facility's policy regarding the wearing of Personal Protective Equipment (PPE) for two of three residents (R) (R360 and R84). Specifically, facility staff failed to don (put on) PPE prior to entering the isolation room of R360, and to perform hand hygiene after doffing (removing) gloves for R84 during pressure ulcer treatment observations.