Continuing Healthcare at Beckett House

Inspectors wroteBased on observation, review of most recent pest report, and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 64 residents who received meals prepared in the kitchen, there was one resident who did not receive from the kitchen. The facility census was 65.

Inspectors wroteBased on work order review, interviews, and observations, the facility failed to ensure resident rooms were kept at comfortable temperatures. This affected 12 residents (#26, #30, #72, #86, #90, #92, #94, #102, #104, #156, #158, #172 ) of 15 reviewed for temperature. The facility census was 65. Findings Include:Review of work orders dated 03/23/26 to 06/18/26 revealed fourteen work orders placed related to heating, ventilation, and air conditioning (HVAC) system in the facility. Interview on 07/15/26 at 2:26 P.M. Resident #30 stated her room was hot. Interview on 07/15/26 at 2:40 P.M. wife of Resident #172 stated the room was hot and was fanning herself with a paper. Interview on 07/15/26 at 3:13 P.M. the Administrator stated the air conditioner repair person was done for the day and had to order a part for the fan in the air conditioner (AC). [...]

Inspectors wroteBased on record review, facility assessment review, job description review, staff schedule review and interview the facility failed to ensure a registered nurse was scheduled for eight consecutive hours, seven days per week. This had the potential to affect all 73 residents residing in the facility. The facility census was 73.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a clean environment. This had the potential to affect 73 of 73 residents in the facility.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure all residents seated at the same table were served their meals at the same time, leaving one resident without food while the other residents ate their meal. This affected one (#29) of three residents reviewed for dining. The facility census was 73.

Inspectors wroteBased on record review and interview the facility failed to develop and implement care plans for behaviors and dementia care for Resident #28. This affected one resident (#28) of two reviewed for a facility reported incident. The facility census was 73.

Inspectors wroteBased on record review, Food and Drug Administration Medication Information review, and interview the facility failed to ensure residents were free of unnecessary medications. This affected on resident (#28) of two reviewed for a facility reported incident. The facility census was 73.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure residents received the correct texture diet. This affected one (#6) of three residents observed for correct diet texture. The facility census was 73.

Inspectors wroteBased on record review, observations, interviews, and policy review, the facility failed to ensure all resident rooms were maintained at a comfortable temperature. This affected seven (#2, #3, #4, #6, #7, #10, and #12) of 13 residents reviewed for heating concerns, and had the potential to affect 13 of 13 residents reviewed for heating concerns. The facility census was 74.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, record review, interview, and review of the facility self-reported incident (SRI), the facility failed to provide care and services to assist a dependent resident with activities of daily living (ADL) and the resident was identified to have maggots in her hair. This affected one (#11) of three residents reviewed for personal hygiene. The facility census was 76.

Inspectors wrote2. Observation on 06/09/25 at 12:13 P.M. of Resident #42 and #224's room revealed a dark yellow orange stain in front of toilet, two broken linoleum with a raised uneven floor by Resident #42's chair and one broken linoleum in bathroom and two going into bathroom. Observation on 06/09/25 at 12:17 P.M. of Resident #68's room revealed the drywall was damaged between her chair and side table. Observation on 06/09/25 at 12:19 P.M. of Resident #65's room revealed five cracked linoleum tile on the floor. Observation on 06/09/25 at 12:40 P.M. revealed Resident #62's walls were damaged with holes behind her chair and to the side of the bed. Observation on 06/09/25 at 3:39 P.M. of Resident #49's room revealed a large hole in the wall behind her bedside table. Observation on 06/09/25 at 5:14 P.M. the wall behind Resident #23's electric wheelchair and the side wall were plastered and not painted. [...]

Inspectors wroteBased on the interview and resident council meeting minute review the facility failed to provide preferred resident activities including community outings to residents in the facility. This affected two residents (#17 and #37) of three residents reviewed for activities. The facility census was 77.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure a psychotropic medication had a 14 day stop date. This affected one resident (#14) of five residents reviewed for unnecessary medication. The census was 77.

Inspectors wroteBased on observation, record review, and interview, the facility failed to clean a dependent resident's eyeglasses. This affected one resident (#23) of four residents reviewed for activities of daily living. The census was 77.

Inspectors wroteBased on record review and interview, the facility pharmacist failed to identify a psychotropic medication needed a 14 day stop date. This affected one resident (#14) of five residents reviewed for unnecessary medication. The census was 77.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure accurate documentation in the medical record. This affected one resident (#12) of one resident reviewed for edema. The census was 77.

Inspectors wroteBased on observation of medication administration, and staff interview , the facility failed to ensure proper hand washing was completed during medication administration. This affected two residents (#50 and #57) of six residents observed for medication administration.

Inspectors wroteBased on the review of the facility job description, personnel record review and staff interview, the facility failed to ensure the Activities Director was qualified for the position. This had the potential to affect 77 out of 77 residents. The facility census was 77.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to maintain a clean and safe living environment for residents. This affected one (#40) of three residents sampled and two additional residents (#6 and #67) identified during environmental tour. The facility census was 78.

Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to provide adequate incontinence care. This affected one (Resident #36) of four residents sampled for activities of daily living. The facility census was 78.

Inspectors wroteBased on observations, interviews, and interviews, the facility failed to ensure the windows were kept in good repair. This had the potential to affect all residents residing in the facility. The census was 67.

Inspectors wroteBased on observation, medical record review, review of glucometer manufacturer information, policy review, and interview, the facility failed to ensure ensure glucometers used for multiple residents were cleaned/disinfected between resident use. This affected four residents (Residents #1, #4, #21, and #36) observed during medication administration. The facility identified 17 residents (Residents #1, #4, #21, #25, #28, #33, #34, #35, #36, #46, #50, #56, #61, #63, #64, #65, and #67) who had blood glucose levels monitored using facility glucometers.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received showers per their preferences. This affected two (Resident #31 and #34) of six residents reviewed for activities of daily living. The facility census was 67.

Inspectors wroteBased on observation, interviews, and policy review the facility failed to maintain residents' personal living space in a comfortable, homelike manner. This affected two residents (Resident #4 and #62) of three residents interviewed for a homelike environment. The census was 67.

Inspectors wroteBased on record review, hospital record review, and interviews, the facility failed to ensure Resident #23 received adequate care for treatment of an urinary tract infection. This affected one resident (#23) of three residents reviewed for urinary tract infections. Facility census was 57. Actual harm occurred on 02/03/24 when Resident #23, who had a diagnosis of Alzheimer's disease and cognitive impairment, exhibited signs of an urinary tract infection including dark, cloudy urine without evidence of timely identification or treatment of the infection. On 02/07/24 at 10:45 P.M. (four days later) the resident was assessed to have an elevated temperature of 102.3 degrees Fahrenheit with altered mental status. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food under sanitary conditions. This had the potential to affect 56 of 57 residents who received food from the facility. The facility census was 57.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were properly assessed for restraints. This affected one resident (#27) of two residents reviewed for restraints. The facility census was 57.

Inspectors wroteBased on medical record review, observation, and interviews the facility failed to ensure assessments were accurate. This affected two residents (#21 and #26) of six reviewed for dental and one resident (#49) of two reviewed for discharges. The facility census was 57.

Inspectors wrote2. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, bipolar, post-traumatic stress disorder. Review of Resident #58's current plan of care revealed no evidence Resident #58 had a plan of care for anxiety disorder, depression, bipolar, post-traumatic stress disorder, behaviors, or refusal of care (showers). Observation on 03/18/24 at 8:00 P.M., revealed strong odors coming from Resident #58's room. Observation and interview on 03/19/24 at 9:30 A.M. with Resident #58, revealed Resident #58 had strong odors coming from his body. The resident voiced no concern regarding receiving assistance with activity of daily living care. The resident reported he needed to apologize to the two aides working last night because he read their body language wrong. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Residents #15, #26, and #46 had quarterly care conferences in conjunction with minimum data sets and failed to revise care plans for Residents #21. This affected four residents (#15, #21, #26, and #46). The facility census was 57.

Inspectors wroteBased no medical record review, observation, and interview the facility failed to ensure residents who were dependent on staff received assistance with activities of daily living (ADL). This affected three residents (Resident #27, #37, and #165) of four reviewed for ADL.

Inspectors wroteBased on record review, hospital record review, observation, and interview the facility failed to ensure wounds were properly identified as healed. This affected one resident (#23) of two residents reviewed for skin conditions. Facility census was 57.

Inspectors wroteBased on record review and interview, the facility failed to provide Resident #15 with an optometry consult. This affected one resident (#15) of two residents reviewed for optometry services. The facility census was 57.

Inspectors wroteBased on medical record review, observation, interviews, and policy review the facility failed to ensure pressure relieving intervention were in-place. This affected one resident (#21) of three residents reviewed for pressure ulcers. The facility census was 57.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure foot care was provided for a resident. This affected one resident (#32) out of four reviewed for activities of daily living. Facility census was 57.

Inspectors wroteBased on record review and interview, the facility failed to provide range of motion services for residents. This affected two residents (#1, #48) of four residents reviewed for range of motion services. Facility census was 57.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure appropriate storage of resident nebulizer equipment. This affected one resident (#58) of one reviewed for respiratory care.

Inspectors wroteBased on record review and interview, facility failed to provide dental services to residents. This affected two residents (#26, #58) of four residents reviewed for dental services. The facility census was 57.

Inspectors wroteBased on medical record review, review of the facility contract, review of dental list, observation, interview, and policy review the facility failed to ensure dental services were offered timely. This affected three residents (#3, #15, and #58) of six reviewed for dental services.

Inspectors wroteBased on record review, McGreer's criteria review, and interview, the facility failed to ensure the criteria was met prior to antibiotics being administered. This affected one resident (#7) out of five residents reviewed for unnecessary medication. Facility census was 57.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #48 was provided adequate assistance during a transfer to the toilet to prevent an injury. Actual Harm occurred on 04/07/22 when Resident #48, who was assessed to require two staff for transfers and toileting was lowered to the floor while being assisted by only one staff member resulting in a displaced fracture of the left femur/hip. The resident was hospitalized as a result of the injury and required surgical repair of the fracture. This affected one Resident (#48) of three residents reviewed for accidents and falls.

Inspectors wroteBased on observation, review of the facility timeline for positive COVID-19 residents and staff, review of resident vaccination status, review of contact tracing, review of facility COVID-19 policies and procedures, review of the current Centers of Disease Control (CDC) Guidance Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes and interview the facility failed to implement adequate infection control measures including comprehensive contact tracing, proper personal protective equipment (PPE) use and implementation of transmission based precautions (TBP) following the identification of COVID-19 positive staff to prevent the spread of infection including COVID-19. This affected three residents (#20, #25 and #303) and had the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #253 and Resident #254 received and signed the appropriate Notice of Medicare Non-Coverage (NOMNC) form. This affected two residents (#253 and #254) of three residents reviewed for beneficiary protection notification.

Inspectors wroteBased on record review, review of a facility Self-Reported Incident (SRI), facility policy and procedure review and interview the facility failed to prevent the misappropriation of the anti-anxiety medication, Xanax prescribed for Resident #304. This affected one resident (#304) of one resident reviewed for abuse and misappropriation of funds/property.

Inspectors wroteBased on record review, review of Pre-admission Screening and Resident Review (PASARR) documentation and interview the facility failed to ensure updated PASARR's were completed following changes in condition, including the identification of mental health diagnoses and psychoactive medications for Resident #12 and Resident #36. This affected two residents (#12 and #36) of two residents reviewed for PASARR.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #5, who was assessed to require staff assistance for activities of daily living (ADL) care received adequate and timely nail care to promote optimal hygiene. This affected one resident (#5) of two residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure all residents received adequate care and treatment. The facility failed to monitor bowel movements for Resident #45, who had a history of constipation, failed to provide thromboembolism-deterrent (TED) hose as ordered for Resident #27 and failed to complete accurate skin assessments to monitor bruising for Resident #202. This affected three residents (#27, #45, and #202) of three residents reviewed for quality of care.

Inspectors wroteBased on record review, review of facility policy and procedure and interview the facility failed to properly assess Resident #48's skin upon admission, timely identify a pressure area and implement a timely treatment to the pressure ulcer wound. This affected one resident (#48) of two residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers.

Inspectors wroteBased on record review and interview the facility failed to provide supplements as ordered to Resident #44 who had experienced weight loss and was on hemodialysis. This affected one resident (#44) of five residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #8 and Resident #28 received the correct administration rate of oxygen as ordered. This affected two residents (#8 and #28) of four residents reviewed for respiratory care.

Inspectors wroteBased on record review and interview the facility failed to complete pre-dialysis and post-dialysis assessments for Resident #44. This affected one resident (#44) of one resident reviewed for dialysis.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to discontinue the medication Acidophilus for Resident #46 timely after a pharmacy recommendation/physician agreement was obtained related to the medication. This affected one resident (#46) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and interview the facility failed to ensure adequate justification for the increase in the medication Depakote prescribed for Resident #51 for agitation related to bipolar disorder. This affected one resident (#51) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to maintain Resident #303's medical record in a complete and accurate manner related to documentation of oxygen rate of administration. This affected one resident (#303) of four residents reviewed for respiratory care.