Bedford Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and clinical record review the facility failed to destroy discontinued Controlled Substances (high potential for abuse) for 2 of 4 residents reviewed (Residents #2 and #6.) The facility reported a census of 30 residents. Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The Care Plan updated on 4/9/25, showed that Resident #6 had impaired cognitive function with intermittent confusion, increased confusion, anxiety, and signs and symptoms of sundowning. Staff were to administer medication as ordered. Her diagnoses included: osteoporosis, anxiety disorder, and delirium due to known physiological condition. According to the orders tab in the electronic chart, Resident #6 had an order dated 12/20/24 at 10:45 AM for lorazepam 0.5 milligrams (mg) one tab every 12 hours As Needed (PRN.) The order was discontinued on 1/4/25.2) The MDS dated [DATE],…

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, clinical record review, staff interviews, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #28) of 12 residents reviewed for care plans. The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #28, dated 8/21/24, included diagnoses of Non-Alzheimer's Dementia and malnutrition. A Brief Interview for Mental Status score of 99, indicated the resident was unable to complete the assessment indicating severe cognitive impairment for decision-making. The MDS further documented the resident wore a wander guard (bracelet on resident to activate an alarm if the resident goes out the facility door) daily. The Care Plan revised on 8/16/24 documented Resident #28 has impaired cognitive function related to dementia. The Care Plan does not include any wandering risk or use of a wander guard. Observation on 9/17/24 at 2:00 PM, Resident #28 resting on bed with wander guard on right ankle. The Electronic Health Record review for the resident…

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, clinical record review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices by contaminating clean surfaces with contaminated gloves and not completing hand hygiene in accordance with standards of practice for 2 of 5 residents (Resident #25 and #28) reviewed. The facility reported a census of 29 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #25 entered the facility on 7/20/24. The MDS also documented a Brief Interview for Mental Status (BIMS) of 99 indicating Resident #25 was unable to complete the interview. The MDS revealed indwelling catheter utilized by Resident #25. On 9/18/24 at 7:31 AM Staff A, Certified Nursing Assistant / Certified Medication Assistant (CNA/CMA) and Staff C, Registered Nurse (RN) entered Resident #25's room, completed hand hygiene, applied gloves, and applied gowns. Staff A cleansed Resident #25's penis with peri wipes. Staff A cleansed Resident #25's…

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, clinical record review, staff interviews, and policy review the facility failed to perform on-going Infection Control surveillance and failed to perform appropriate hand hygiene for 1 of 5 residents (Resident #77) during resident care. The facility reported a census of 26 residents. Findings include: 1. On 5/01/24 at 11:40 AM, a review of the facility's surveillance binder indicated Infection Control surveillance documentation had not been completed. A document titled Infection Control: Regulations Governing Implementation dated April 2018 indicated the facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. On 5/01/24 at 11:48 AM, the Infection Preventionist (IP) completed surveillance sheets since the facility's last survey could not be located. She stated the facility only had documentation…

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 clinical record review, facility record review, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of discharge/transfer of residents as required for 2 of 3 residents reviewed who were discharged or transferred from the facility (Residents #14, and #22). The facility reported a census of 26 residents. Findings include: 1. A Minimum Data Set (MDS) for Resident #14 dated 4/13/24, included diagnoses of renal (kidney) failure and diabetes. Review of Resident #14's clinical record census sheet revealed the resident transferred to the hospital 1/7/24 and returned to the facility 1/10/24. Review of the facility's Notice of Transfer Form to Long Care Term Ombudsman form for 1/2024 lacked documentation of Resident #14's transfer to the hospital. 2. A Minimum Data Set for Resident #22 dated 3/29/24, included diagnoses of heart failure and diabetes. Review of Resident #22's clinical record census sheet revealed the resident transferred to the hospital 11/26/23 and returned to the facility 12/4/23. Review of the facility's Notice of Transfer…

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 resident interview, clinical record review, facility record review, staff interview, and policy review the facility failed to provide the resident or resident representative with a bed-hold notice at the time of transfer for hospitalization as required for 2 of 3 residents (Residents #14, and #77). The facility reported a census of 26 residents. Findings include: 1. A Minimum Data Set (MDS) for Resident #14 dated 4/13/24, included diagnoses of renal (kidney) failure and diabetes. Review of Resident #14's clinical record census sheet revealed the resident transferred to the hospital 1/7/24 and returned to the facility 1/10/24. Resident #14's bed-hold policy/authorization dated 1/7/24 documented bed hold policy/authorization completed, printed and given to resident, representative and/or sent with hospital transfer paper work with no documentation of the resident/representative confirmation, if confirmation was given or how, and the bed-hold rate. 2. A Minimum Data Set (MDS) for Resident #77 dated 4/24/24, documented Resident #77 admitted to the facility 4/24/24. Review of…

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 clinical record review, staff interview, and policy review the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days for a resident placed on hospice care for 1 of 2 residents (Resident #18) reviewed. The facility reported a census of 26. Findings include: The Minimum Data Set (MDS) assessment for Resident #18 dated 3/9/24, included diagnosis of non-Alzheimer's dementia. The assessment indicated the resident had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment for decision making. Review of Resident #8's Clinical Physician Orders revealed an order for the resident to receive hospice services effective 4/4/24. On 4/30/24 at 3:41 PM, review of Resident #18's MDS list documented the status of a Significant Change started 4/18/24 and status of still in progress. Facility policy Resident Assessments revised November 2019 documented a Significant Change in Status Assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guidelines for decline and a SCSA…

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 facility document review and staff interview the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. The facility reported a census of 26. Findings include: Review of facility's nursing schedule for 3/29/24 - 5/1/24 revealed no RN scheduled to work on 4/14/24. Interview on 5/01/24 at 4:30 PM, the Administrator confirmed the facility had no RN coverage in the building on 4/14/24 and stated the facility follows the federal regulations of RN coverage 8 hours a day and his expectation is for RN coverage 8 hours a day.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review, and staff interview, the facility failed to report a Veterans Affairs (VA) eligible resident to the Iowa Department of Veterans Affairs (IDVA) within 30 days of admission for 1 of 10 residents (#6) reviewed. The facility reported a census of 26 residents. Findings include: On 4/30/24, review of the VA Eligibility list revealed Resident #6 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) for Resident #6 dated 1/15/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 08 out of 15, indicating moderately impaired cognition. It included diagnoses of a fracture around the left knee prosthesis, acute respiratory failure, and non-Alzheimer's dementia. The MDS indicated dependence with toileting, bathing, and dressing and required maximal assistance with oral and personal hygiene. The resident's Electronic Health Record (EHR) indicated the resident received Physical and Occupational Therapy (PT/OT) and listed…

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 interview with residents and staff, record review and policy review the facility failed to keep residents safe from sexual exploitation for 1 of 5 residents reviewed. Resident #5 participated in mental health group sessions at the hospital three times a week. The hospital provided transportation to and from the sessions and the driver became intimate with Resident #5. The facility reported a census of 26 residents. Findings include: According to the admission Minimum Data Set (MDS) dated [DATE] Resident #5 admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficits) no behavioral symptoms. He was independent with hygiene, dressing, transfers and walking. Diagnosis included Benign Prostatic Hyperplasia (enlargement of prostate glands), non-Alzheimer's Dementia and depression. The Care Plan dated 10/14/23, indicated that Resident #5 moved to the facility from his private residence due to a decline in his cognitive abilities and he was unable…

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 and policy review and interviews the facility failed to report potential abuse for 2 of 5 residents reviewed. Resident's #6 and #9 reported to staff that another resident had made sexual advances toward them. Staff failed to report these concerns to the proper state agency. The facility reported a census of 26 residents. Findings include: 1) The Minimum Data Set (MDS) dated [DATE], showed that Resident #6 had a BIMS score of 15 (intact cognitive ability). The resident had no behavioral symptoms, was independent with transferring, hygiene and dressing. Her diagnosis included anxiety disorder, depression, diabetes mellitus and muscle weakness. The Care Plan updated on 2/29/24, showed that Resident #6 had a history of abuse and requested female care givers only. She was on antidepressant medication and had psychosocial wellbeing problems related to family discord, ineffective coping. Staff were directed to allow her time to answer question and to verbalize her feelings, perceptions and fears. Staff…

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 interview, record review and policy review the facility failed to investigate injuries consistent with abuse for 1 of 3 residents reviewed (Resident #2). Resident #2 sustained a femur fracture and scattered bruising, the facility failed to investigate these injuries. The facility reported a census of 26 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #2 was unable to complete a Brief Interview for Mental Status (BIMS) assessment (severe cognitive deficit). He was independent with sit to stand, sit to lying and toilet transfers. The Significant Change MDS dated [DATE] showed that he returned from a hospitalization, and was totally dependent on staff to assist with sit to stand, sit to lying and toileting transfers. Diagnosis for Resident #2 included; dementia, arthritis, diabetes, renal insufficiency and coronary artery disease. The Care Plan updated on 1/11/24 showed that Resident #2 was at risk for falls and had a history of falling. He required one…

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 adequately monitor and intervene for 3 of 3 residents reviewed (Residents #2, #6 and #9). Resident #2 had fluctuating oxygen saturation, with supplemental oxygen as needed. Staff failed to assess the resident's oxygen status for a period of 4 days. Residents #6 and #9 reported to staff that a male resident made unwanted advances towards them. Staff failed to investigate and assess the residents. The facility reported a census of 26 residents. Findings include: 1) According to the Significant Change Minimum Data Set (MDS) dated [DATE], Resident #2 was unable to complete a Brief Interview for Mental Status (BIMS) assessment (severe cognitive deficit). He was on oxygen therapy and totally dependent on staff to assist with sit to stand, sit to lying and toileting transfers. Diagnosis for Resident #2 included; dementia, arthritis, diabetes, renal insufficiency, pneumonia, and coronary artery disease. The Care Plan updated on 2/29/24 showed that…

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 prevent accidents for 1 of 3 residents reviewed (Resident #2). On 2/7/24, staff sent Resident #2 to the emergency room due to abdominal pain, and an X-Ray exam revealed that the resident had a fracture to the right femur. The facility failed to investigate the injury of unknown origin. Staff transferred Resident #2 with the use of a mechanical lift, sit to stand. They kept the resident in the standing position on the lift while they cleaned his gluteal area of bowel movement (BM), and the resident became fatigued and had difficulty standing. The facility reported a census of 26 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #2 was unable to complete a Brief Interview for Mental Status (BIMS) assessment (severe cognitive deficit). He was independent with sit to stand, sit to lying and toilet transfers. An MDS dated [DATE], showed that the resident returned from a hospitalization and had…

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.