Bourne Manor Extended Care Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the manufacturer's directions for application of a registered pesticide (Environmental Protection Agency (EPA) Registration #44446-80) to prevent exposure to residents. Specifically,1. On six evenings over a three-week span, the facility applied a pesticide in the main kitchen without protective measures in place to prevent cross contamination of the pesticide on food prep surfaces, kitchen equipment, condiment packages, small food carts (used to deliver nourishments to the kitchenettes), and meal trucks. The facility failed to clean the food contact surfaces (dishes, pots, pans, cutting boards, utensils), equipment, and carts, after the application, including the inside and outside of the meal trucks which were used to deliver food trays to the units and residents' rooms.2. [...]

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Monitor the dishwasher sanitation chemical agent after switching from high temperature dishwasher to chemical sanitation for undetermined time frame to ensure all dishware was properly sanitized; and2. Ensure the main kitchen, dish room, and food dry storage area was maintained in clean and sanitary condition; and 3. Ensure wastewater from the broken garbage disposal was not allowed to openly discharge on dish room floor for 70 days before being repaired.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to:1. Promptly repair or replace a broken garbage disposal resulting in raw sewage overflowing onto to the dish room floor, resulting in dietary staff squeegee the sewage discharge across the room to the open drain;2. Promptly fix leaking water from the recent replacement garbage disposal resulting in water draining on the dish room floor with active cock roach infestation present. 3. Promptly fix heat booster which broke in January 2025;4. Promptly obtain an electrician to repair the electrical short resulting in the plate warmer and refrigerator in main kitchen being inoperable for approximately two weeks.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement an effective pest control program to ensure the facility was free of cockroaches. Specifically, the facility had an active cockroach infestation in the main kitchen, with additional staff sightings in the food trucks during meal delivery, in the unit nurses' stations, unit kitchenettes, and the employee breakroom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for two Controlled Substance Registers (controlled substance log books) reviewed out of six Controlled Substance Registers in use by the facility. Specifically, the facility failed:a. For Residents #139, #13, #120, #140 and #100, to ensure controlled substance registers have complete and accurate documentation upon the removal of narcotics that are discontinued from use, including all signatures required; andb. To ensure controlled substance disposal records were fully completed and maintained by the facility after the narcotics were destroyed, for accurate monitoring of destruction of narcotics.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff notified the physician in a timely manner of a recommendation for a medication change from the consulting Psychiatric Nurse Practitioner (PNP) for one Resident (#116), out of a total sample of 25 residents. Specifically, the facility failed to notify the physician of the PNP's recommendations to decrease Cymbalta (an antidepressant medication) from 60 milligrams (mg) to 30 mg and add Zoloft (an antidepressant medication) 25 mg due to depression.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for one Resident (#143), out of a total sample of 25 residents. Specifically, the facility failed to ensure pharmacy medication labels were followed for Resident #143.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident with an alteration in skin integrity related to a wound, specifically moisture associated skin damage (MASD), received necessary treatment and services in accordance with professional standards of practice to promote healing for one Resident (#129), out of a total sample of 25 residents. Specifically, the facility failed to transcribe and implement recommendations from the Wound Care Consultant for one month and ensure a pressure relieving air mattress was inflated properly. Findings Include:Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification:- The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of four nurses observed during the medication pass made two errors out of 30 opportunities, resulting in a medication error rate of 6.67%. Those errors impacted two Residents (#143 and #49).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure staff followed hand hygiene procedures prior to handling medication(s) and after administering medication(s) and that staff handled medications in a sanitary manner to prevent potential transmission of infections.

Inspectors wroteBased on interviews and observations, the facility failed to ensure it provided a clean, comfortable, and homelike environment for the residents residing on two units (Units 2 and 3) out of three units.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medications were not left unattended in Resident #124's room.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable disease and infection, for two Residents (#76 and #105), of a total sample of 24 sampled residents. Specifically, the facility failed: 1. For Resident #76, to ensure the Resident's respiratory equipment was maintained in a safe, clean and sanitary condition; and 2. For Resident #105, to ensure proper infection control measures, specifically handwashing, were implemented during a gastrostomy tube dressing change.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had significant cognitive impairment, was unaware of his/her care needs and resided on the dementia unit, the facility failed to ensure he/she was free from physical and sexual abuse by another resident. On 11/19/23 at approximately 1:30 P.M., Resident #2, was found in his/her roommate's bed without any pants on and he/she was laying on top of and between the legs of Resident #1 who had no clothes on. Resident #2 was observed thrusting his/her genital area into Resident #1's pelvic/genital area, and when found by staff, Resident #2 yelled at staff to get the hell out and was extremely agitated. The residents were immediately separated by staff. [...]

Inspectors wroteBased on records review and interviews for one of three sampled residents (Resident #2) who had been recently admitted to the facility in October of 2023, and whose admission referral paperwork provided to the facility included an allegation that he/she had choked his/her significant other, and who since his/her admission had made sexually inappropriate comments to female staff members, had grabbed a female staff members' top in an attempt to look at her breasts while she was giving him/her a shower, and on at least once occasion approached another residents' room and asked that resident if he/she was just going to stand there or get into bed with him/her, the facility failed to ensure they developed and implemented a comprehensive care plan that specifically addressed Resident #2's sexually inappropriate behaviors that included interventions, measurable goals and outcomes. [...]

Inspectors wroteBased on interviews and records reviewed for one of three sampled residents (Resident #1) the Facility failed to ensure they obtained and maintained evidence that their investigation was conducted in a manner consistent with Federal Regulations and Facility Policy, which included ensuring their investigation was thorough, when on 11/19/23 nursing staff failed to conduct and document their physical examination of Resident #1 following a resident to resident incident of sexual abuse.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had significant cognitive impairment, was unaware of his/her care needs and resided on the dementia unit, the Facility failed to ensure nursing staff members provided care and services that met professional standards of practice, when on 11/19/23, after an alleged incident of resident-to-resident sexual abuse (potential sexual assault) Nurse #1 was heard, by multiple staff members making unprofessional comments regarding the incident in Resident #1's (the alleged victims) room, in his/her presence, during which she implied that Resident #1 had been flirting with Resident #2 (the alleged perpetrator) all day and needed to more careful.

Inspectors wroteBased on interview and record review, the facility failed to conduct initial or annual comprehensive assessments through completion of Minimum Data Set (MDS) assessments for four Residents (#1, #56, #24, and #219).

Inspectors wroteBased on interview and record review, the facility failed to conduct quarterly assessments timely through completion of Minimum Data Set (MDS) assessments for seven Residents (#62, #83, #74, #6, #29, #49, and #90).

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for four Residents (#115, #116, #24, and #103).

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was stored, labeled, dated, and maintained under sanitary conditions in the main kitchen reach-in refrigerator; 2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene and to prevent cross contamination. In addition, ensure the use of gloves was limited to a single use task; and 3. Ensure resident food re-heating instructions and thermometer were available in three of three resident kitchenettes and maintain a microwave in clean and sanitary condition for one of three resident kitchenettes.

Inspectors wroteBased on observation and interview, the facility failed for two Residents (#11 and #66), to ensure that equipment was in good working order. Specifically, the facility failed to ensure: 1. Resident #11's portable air conditioning (AC) unit was in good working order, cleaned, and had routine maintenance; and 2. Resident #66 had a safe, functioning bed control.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#114) representative, as designated by the Resident, was able to make medical decisions for the Resident, in a sample of three closed records reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive Minimum Data Set (MDS) assessment for significant change, for one Resident (#42), from a total sample of 25 residents.

Inspectors wroteBased on interview and record review, the facility failed to transmit timely, through completion of Minimum Data Set (MDS) assessment, the death of Resident #101.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that individualized, resident centered, comprehensive care plans were developed and consistently implemented for one Resident (#103), out of a total sample of 25 residents. Specifically, for Resident #103, the facility failed to ensure a care plan was developed for: a. the use of psychotropic medications (e.g., antianxiety, antidepressant and antipsychotic) that included individualized, resident centered targeted signs/symptoms or behaviors, and b. person centered dementia care.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to follow their policy and physician's orders by not administering bowel medication as ordered, and not monitoring and documenting bowel assessments to prevent constipation issues for one Resident (#105), out of a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff provided respiratory care consistent with facility policy for three Residents (#14, #35, and #46). Specifically, the facility failed to ensure the oxygen concentrator filter was clean and free of dust build up.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure targeted behaviors and signs and symptoms of adverse reaction/side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one Resident (#103), out of a total sample of 25 residents.