Focused Care at Beechnut

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents and supervision, in that:The facility failed to ensure CR #1 did not elope from the facility on 3/21/26. The facility did not realize he had left through a window in room [ROOM NUMBER] and exited the facility through the fence. Resident #1 was found by a staff member in front of a store located approximately 2.5 miles away. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/21/26 and ended on 03/21/26. The facility had corrected the non-compliance before the survey began on 04/15/26. The IJ template was sent to the Administrator on 04/16/26 at 3:18 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that:1-10 pounds roll of Ground Beef had a temperature of 75 degrees Fahrenheit. This failure could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Observation and interview on 08/19/25 between 8:30 am and 8:40 am with the Dietary Manager revealed 1-10 pounds roll of ground beef observed. The roll was a potentially hazardous/time control for safety food as it was inappropriately being held on a pan on top of the stove. The Dietary Manager measured the roll on the stove, and it had an internal temperature 75 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 4 of 4 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection. Observation on 08-19-25 at 8:45 am, with the Dietary Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had 4 commercial -size dumpsters and the lids and doors were open. Interview on 08-19-25 at 9:00 am, with the Dietary Manager he stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. He also stated that nursing, housekeeping and dietary dispose their garbage in the dumpster and place residents at risk of infection. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 3 of 5 residents (Residents #103, #101, and #36) reviewed for call lights.-The facility failed to ensure Resident #103, Resident #101's, and #36's call lights within reach. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life. Resident #103Record review of Resident #103's face sheet 08/22/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #103 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and Alzheimer (a progressive brain disease that cause memory loss). [...]

Inspectors wroteBased on observation, interview 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 transmission of communicable diseases and infections for 3 of 4 residents (Resident #103, Resident #34, and Resident #1) and 1 (Station A) of nurse's stations reviewed for infection control. 1. The facility failed to ensure CNA U followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #103. 2. The facility failed to ensure LVN Z followed appropriate infection control and hand hygiene procedure during Accu check for Resident #34.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system for 1 of 5 residents (Resident #103) reviewed for call light button placement and for 3 (102, 104, and 105) of 4 resident doors reviewed for working call lights systems. The facility failed to ensure Resident #103's call light was functioning properly. The facility failed to ensure emergency call lights in the restroom was illuminated over 3 doors of rooms 102, 104 and 105 on 8/19/25These failures could place residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed was free of pests and rodents for the months of March 2025 and August 2025 reviewed for environment.-The facility failed to ensure the facility was free of roaches in the dining room, residents' rooms, nursing station and in the dietary department. These failures could place residents at risk of disease, infection and a decline in their physical health. Roaches were observed in the dining room, resident's rooms, nursing station and in dietary department. 2. During the group interview, some residents complained about roaches they had observed a month ago. Interview with the Dietary Manager on 08-19-25 at 9:00AM revealed that the department had issues on roaches and gnats last month, but the issue is getting better. The walls and baseboards of the kitchen appeared to be sealed with no concerns. [...]

Inspectors wroteBased on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 1 (CR #59) of 3 resident reviewed for MDS transmission. -The facility failed to transmit a completed Discharge MDS assessment for CR# 59 within 14 days of completion. These failures could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services. Record review of CR# 59's admission Record dated [DATE] revealed a [AGE] year-old male. CR# 59 had an admission date of [DATE] and discharge date of [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #15 and #78) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #15 being placed back into the secured unit on 07/31/2025. 2. The facility delayed care-planning Resident #78 for being on hospice after she was admitted on [DATE]. She was care-planned on 4/24/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 (Resident #76) of 4 residents and 1 of 3 medication carts reviewed for accident hazards. -The DPS (Maintenance Director) left a portable flashlight with its light turned on and unsecured in Resident #76's bathroom on 09/21/2025. - The facility failed to properly dispose a blue disposable razor/shaver, and a syringe used for injections within the sharps contain attached to the side of 1 (station A) of 3 medication carts. These failures could put residents at potential risk of harming themselves or others with unsecured equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #10) of two residents reviewed for tracheotomy care.-The facility failed to ensure LVN A used sterile technique during tracheotomy suctioning for Resident #10 on 8/20/25. This failure placed residents who required respiratory care at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Record review of Resident #10's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted [DATE]. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 (station B) of 3 nurse medication carts reviewed for medications storage, in that:- LVN B left one medication container on top of the medication cart and went into a resident's room during medication administration. This failure could affect residents, placing them at risk for taking medication which could affect residents' health, requiring medical intervention and drug diversion. Record review of Resident #1's face sheet dated 08/20/25 revealed he was a [AGE] year-old male initial admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for one of twenty-one residents (Resident #1) reviewed for accident hazards and supervision. -The facility failed to ensure Resident #1 had adequate supervision on 8/16/2024 which allowed her to elope from the facility. She was not found until 8/17/24 when she was admitted to the emergency room with complaints of heat exhaustion and weakness. The noncompliance was identified as past noncompliance and the Administrator was given the IJ Template on 8/29/24 at 2:23 pm. The IJ began on 8/16/2024 and ended on 8/18/2024. The facility had corrected the noncompliance before the investigation began on 8/18/2024. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 5 residents (Resident #72) reviewed for a change of condition. The facility failed to notify the physician regarding Resident #72's missed urologist appointments on 3/14/2024 and 5/23/24, and failed to communicate Resident #72's changing skin condition of the groin and resident's report of pain until around 06/10/2024, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw. On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified and the template was presented to the Administrator and the Interim DON. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #72 and #54) reviewed for quality of care. 1. The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident # 72's skin condition of the groin and resident's report of pain, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw, and failed to ensure that Resident #72's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter. 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to care for residents in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #20, Resident #33, and Resident # 54), reviewed for resident rights. -CNA K was standing while feeding Resident #54 his breakfast on 06/25/24. -LVN B did not provide privacy when administering insulin to Resident #33 on 06/25/2024. -RN A did not provide privacy when administering Resident # 20 G-tube medications on 06/25/2024. This failure placed residents at risk for feeling embarrased, disrespected and diminished quality of life.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs for 1 of 1 resident (Resident #72) reviewed for anticoagulants. The facility did not develop and implement a comprehensive person-centered care plan to address Resident #72's use of anticoagulants. There was no documentation in his care plan of measurable objectives, interventions, or timeframes for how staff would meet his needs. This failure affected 1 resident and has the potential to affect residents who use anticoagulants by not having his needs met and putting him at risk of being inappropriately cared for.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were dated as opened/preparation discarded after 72 hours. 3. The facility failed to thaw frozen Fish Filet These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 06/25/24 at 8:15 AM revealed the following. 1. 2 tubs Plastic Container of Cottage Cheese in the walk in cooler with manufacturer expiration date of 6/14/24. 2. A Plastic container of Shredded Cheese in the walk in cooler with no date opened and no use by date. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for dumpster A and Dumpster B of 2 dumpster reviewed for Food and nutrition services. -The facility failed to ensure dumpster A and dumpster B's lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #72) of four residents observed for infection control. The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 5 staff (DHK, LSA, and CNA B) observed for infection control. 1. The facility failed to ensure that CNA B changed his gloves and perform hand hygiene while providing indwelling catheter and incontinent care to Resident #72. 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible for 1 of 6 residents (Resident #86) reviewed for accident hazards. The facility failed to prevent a disposable razor and hygiene products from being located unsupervised in Resident #86's room. This deficient practice could result in residents coming into contact with dangerous materials which could place them at risk of injury or death.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 22 residents (CR #1) reviewed for a change of condition: -The facility failed to immediately inform CR#1's physician after a change in condition. -The facility failed to notify the Physician when CR #1 had a choking episode on 04/22/24 and experienced a change in condition. -The facility failed to notify CR #1's RP when she experienced a change in condition - CR #1 passed away on 04/27/202418 at the hospital. An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 12:54 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 22 residents (CR #1) reviewed for care plans. - The facility failed to ensure CR #1 had a Comprehensive Care Plan to address her diagnosis of dysphagia (difficulty swallowing). -The facility failed to have interventions in place when CR #1 experienced a choking episode on 04/22/2024. On 04/25/2024 CR #1 experienced another choking episode and was transferred to the hospital. - CR #1 passed away on 04/27/2024 at the hospital. An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 1:07PM. While the IJ was removed on 05/02/2024 at 5:17PM. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received adequate supervision and assisted device to prevent accidents for 1 of 22 residents (CR #1) reviewed for accidents. -The facility failed to intervene by putting interventions in place when CR #1 began having choking episode during eating on 04/22/24. -The facility failed to in-service staff on the s/s of silent aspiration and choking. -The facility failed to monitor CR #1 during meals after she had a choking episode on 04/22/24. CR #1 experienced another choking episode on 04/25/2024 and had to be transferred to the hospital via 911services. CR #1 passed away at the hospital on [DATE]. This failure could place residents at risk for choking/silent aspiration that could lead to death. An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 1:07PM. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 10 residents (CR #1) reviewed for Quality of Care. 1. The facility failed to immediately transfer CR #1, who was cognitively impaired and received Eliquis (an anticoagulant/blood thinner) when CR #1 went to the hospital after an unwitnessed fall on 09/22/2023 at 4:55 a.m. and sustaining a head injury. CR #1 was transferred to the hospital via non-emergency transportation service as a replacement for 911 emergency services. An Immediate Jeopardy (IJ) was identified on 01/18/2024 at 10:49 a.m. The IJ template was provided to the facility on [DATE] at 10:49 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. 1. CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m. 2. CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. 3. CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24. An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (CR#1 and Resident #2) reviewed for clinical records. -The facility failed to ensure staff documented wound care treatments on CR#1 and Resident #2's MAR/TAR. This failure could affect residents that received wound care and place them at risk of inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 5 of 15 residents (Residents #321, #80, #34, #43, and #53) reviewed for accidents and supervision. 1. The facility failed to ensure the memory care courtyard gate was locked. Resident #321 left the courtyard through the unlocked gate, after being left unsupervised by the MA A, and was headed toward the front of the facility. 2. The facility failed to train staff to monitor the memory care courtyard gates to ensure they were locked. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the commercial oven, stove and wall were not soiled with any gummy/greasy substances. 2. The facility failed to ensure the deep fryer was not full of odiferous grease. 3. The facility failed to ensure 7 full-size sheet pans did not have baked-on brown substances. These deficient practices could place residents at-risk by contributing to foodborne illness, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 2 residents (Resident #65) reviewed for oxygen therapy. The facility failed to ensure Resident #65's oxygen was set according to physician orders. This failure could place residents at risk of respiratory distress.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6% based on 2 errors out of 31 opportunities, which involved 2 of 7 residents (Residents #36 and #32) reviewed for medication errors. 1. MA CC failed to apply Resident #36's lidocaine patch to the knee and foot, according to physician orders and applied a Lidocaine patch to Resident #36's shoulder only. 2. LVN Z failed to administer Reglan to Resident #32 according to physician orders and administered 12 mL instead of 10 mL. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure there was a communication process, which included how the communication would be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for 1 of 2 residents (Resident #64) reviewed for hospice services. -The facility failed to ensure there was hospice communication documentation for Resident #64 in her medical record or hospice communication binder. This deficient practice could place residents at risk of treatments and services not being coordinated.

Inspectors wroteBased on observation, interview 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 to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #9) reviewed for infection control. CNA A failed to properly change gloves and wash or sanitize her hands when moving from a dirty area to a clean area when incontinent care was provided to Resident #9. This failure could place residents at risk for cross contamination, infections, delay in treatment and hospitalization.