Bellway Health And Rehabilitation Center

Based on observation, interview, the facility's 2024 Spring/Summer (S/S) Menu Diet Spreadsheets, the facility's production sheets, the facility's scoop/disher/dipper chart, and the facility's policies for The Dining Experience: Objectives, Menu Planning and Requirements, Menu Diet Spreadsheets/Portion Serving Communication Tool, Use of Production Sheets, and Menu Substitutions or Changes and Approval; the facility failed to provide pureed food items in the portions specified on the menu for supper on Tuesday, 07/09/2024 and for lunch on Thursday, 07/11/2024. The facility further failed to include cheese in the pureed entree as specified on the menu for supper on Tuesday, 07/09/2024 and did not receive approval from the Registered Dietitian (RD) to do so. In addition, the facility failed to provide the portion specified on the menu for Coleslaw on the Regular texture diets at supper on Tuesday, 07/09/202, for trays on the [NAME] Wing cart. the facility also failed to provide the portion of ground Bratwurst for the Mechanical Soft texture diets as specified on the menu for lunch on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and the facility policy titled, Safe and Homelike Environment, the facility failed to ensure two of six shower rooms on the South unit in the facility were free of soap build up on the walls and dark coloring on the floors. This affected Resident Identifier (RI) #108, and two of 11 shower rooms in the facility; however, the deficient practice had the potential to affect all 60 residents residing on the South unit who used the shower rooms. This deficient practice was cited as a result of the investigation of complaint/report number AL00048274. The facility further failed to ensure the left arm rest on RI #73's wheelchair (WC) was not torn. This affected RI #73, one of one resident observed with a torn WC armrest. Findings Include: Review of an undated facility policy titled, Safe and Homelike Environment, documented: Policy: In accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment, . Sanitary includes, but is not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, group council meeting, and review of facility policy titled Resident and Family Grievances, the facility failed to ensure grievances filed by Resident Identifier (RI) #40 and RI #116 on 05/14/2024, 05/21/2024, and 05/30/2024 were resolved in a timely manner. Further, the facility failed to take prompt action to update complainants of progress towards a resolution. This deficient practice affected two of two residents sampled for grievances. Findings Include: A review of an undated policy titled Resident and Family Grievances revealed the following: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances . Definitions: Prompt efforts to resolve include . actively working toward resolution of that complaint/grievance . Procedure: . d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions on the form . e. The Grievance Official, or designee, will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews and review of a facility policy titled, Restraint Free Environment, the facility failed to ensure Resident Identifier (RI) #73's wheelchair (WC) seat belt was released during meal times on three of seven days of the survey 07/09/2024, 07/12/2024, and 07/15/2024. This deficient practice affected RI #73, one of one resident reviewed for the use of restraints. Findings include: RI #73 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Unspecified Convulsions and Cerebral Palsy. Review of a facility policy titled, Restraint Free Environment, with a Copyright date of 2023, revealed the following: . Definitions: Physical Restraints refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Compliance Guidelines: . 5. Before a resident is restrained, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, and staff interview, and review the facility policy titled Restorative nursing Programs, the facility failed to ensure a splinting device for Resident Identifier (RI) #64's hand was in place on 07/09/2024 and 07/11/2024 to prevent decreased Range of Motion (ROM). Findings Include: Review of an undated facility policy titled Restorative Nursing Programs documented: Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Definition: . This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. RI #64 was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis. RI #64's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2024 noted RI #64's Brief Interview for Mental Status (BIMS) score to be 15 of 15 which indicated intact cognition. Review of RI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, review of a facility policy titled, Abuse, Neglect and Exploitation, and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #51 was free from misappropriation of funds from his/her personal funds. On 05/30/2024 RI #51 reported she was missing his/her money pouch and money. The money pouch and some of the money was later located in RI #123's bedside drawer. This deficient practice affected RI #51, one of 17 residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00048010. Findings Include: A review of the facility Abuse, Neglect, and, Exploitation Policy, , revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit .misappropriation of resident property . Definitions: .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, review of Fundamentals of Nursing, Ninth Edition, [NAME] and Perry and review of a facility policy titled Administering Medications, the facility failed to ensure licensed staff remained with Resident Identifier (RI) #18 and observed to ensure accurate and complete medication administration. This was observed on 4/27/21 during the initial tour of the facility and affected one of one resident observed with medications at the bedside. Findings include: Review of Fundamentals of Nursing, Ninth Edition, [NAME] and Perry, page 618, revealed the following: . BOX 32-2 Evidence-Based Practice . Application to Nursing Practice . nurses need to remain vigilant and consistently follow medication administration policies and protocols to ensure safe medication administration. Further review of Fundamentals of Nursing, Ninth Edition, [NAME] and Perry, page 657, revealed: .Chapter 32- Medication Administration . l. Do not leave medications unattended . A facility policy titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, review of the facility policy titled Isolation- Categories of Transmission-Based Precautions and review of the facility's COVID -19 Pandemic Plan, the facility failed to ensure staff donned Personal Protective Equipment (PPE) prior to entering Resident Identifier (RI) #206's room, a resident on isolation, when delivering the supper tray and assisting with tray set up. This was observed on 4/27/21 and affected one of three sampled residents on Transmission-Based Precautions. Findings include: Review of the facility's COVID-19 Pandemic Plan, revised 4/5/2021, revealed: . RESIDENT MONITORING. 1. * In the event the facility had to admit or readmit a known or suspected Covid-19 positive resident the following measures would be implemented: All admissions or readmissions will be placed in 14-day quarantine . Respiratory Isolation/quarantine precautions would be initiated. Review of a facility policy titled, Isolation - Categories of Transmission-Based Precautions,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and a review of facility policy titled Food Storage, the facility failed to ensure: 1. cooked sausage patties and cheese slices were completely wrapped in the walk-in refrigerator and 2. items in a unit resident refrigerator were labeled and dated properly. The food items in the walk in refrigerator had the potential to affect 109 residents receiving meals from the kitchen and the unit resident refrigerator affected one of two unit resident refrigerators. Findings Include: A review of a facility policy titled Food Storage with no date, revealed POLICY : Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing . PROCEDURES .15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. 1) 06/04/19 at 2:35 PM, during the initial tour of the kitchen, the surveyor observed individual sausage patties wrapped in aluminum foil not, completely covered on the middle shelf of the walk in refrigerator. On the top shelf was a package of cheese…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an Annual Minimum Data Set (MDS) assessment, dated 1/28/19, accurately reflected the stage of a pressure injury on admission for Resident Identifier (RI) #64. This affected RI #64, one of two resident's whose MDS was reviewed for accurate staging of pressure injury. Findings Include: RI #64 was admitted to the facility on [DATE]. RI #64's diagnoses included pressure ulcer of right hip unstageable, idiopathic scoliosis and spina bifida. A review of RI #64's Annual MDS, dated [DATE], indicated the resident's most recent admission date was 9/25/14. The MDS also revealed: . Section M . M0300 . C. 0 stage 3 pressure ulcers . D. 1 stage 4 pressure ulcer .1 stage 4 present upon admission . A record review of RI #64's Quarterly MDS dated [DATE] revealed . Section M . M0300 . C. 1 stage 3 pressure ulcers . 1 stage 3 pressure ulcer present upon admission . D. 0 stage 4 pressure ulcer . No number was indicated for the number of stage 4's present upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) did not clean bowel movement from Resident Identifier (RI) #61, then with the same soiled gloves place a clean pad, remove moisture barrier from the resident's bedside cabinet and apply moisture barrier to the resident. This was observed on 6/6/19 and affected RI #6, one of one resident's observed for incontinent care. Findings Include: RI #61 was admitted to the facility on [DATE]. Diagnoses included Morbid severe obesity due to excess calories and Lymphedema. A review of RI #61's Quarterly Minimal Data Set with an Assessment Reference Date of 4/17/19 revealed RI #61 required a one person extensive assistance with toileting needs. On 6/06/19 at 10:30 AM, the surveyor observed incontinent care for RI #61, performed by Employee Identifier (EI) #2, CNA. EI #2 washed her hands, put on gloves and prepared the needed supplies. EI #2 changed gloves after washing hands and performed the incontinent care.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.