Beardstown Health & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement appropriate infection control measures for residents with signs and symptoms of a potentially communicable skin condition. The facility failed to initiate/implement contact isolation precautions, failed to obtain a diagnosis and track the infection, and failed to clarify physician orders through the infection preventionist for two (R2, R3) of six residents reviewed for communicable diseases in a total sample of six residents. Findings include:The facility's General Approaches to Infection Prevention and Control Standard and Transmission Based Precautions for Communicable Diseases dated October 17th, 2022 documents contact precautions used in addition to standard precautions are intended to prevent transmission of pathogens that are spread by direct person to person or indirect contact with the resident or environment examples (C. diff, norovirus, and scabies) and require the use of appropriate personal protective equipment (PPE) including…

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 document a diagnosis and target behaviors to warrant the use of anti-psychotic medications, and failed to treat underlying conditions prior to initiating and increasing anti-psychotic medication doses for six of nine (R27, R32, R54, R57, R62, and R65) reviewed for anti-psychotic medication use with the diagnosis of Dementia or Alzheimer's Disease in the sample of 35. Findings include: The facility's Antipsychotic's policy dated 04/2015 documents, 1.) Diagnosis alone does not warrant the use of anti-psychotic medications. The following criteria also needs to be met: a) The behavioral symptoms present a danger to the resident or others and one or both of the following: b) The symptoms are due to mania or psychosis. c) Behavioral interventions have been attempted and documented in the care plan. 2.) Enduring Conditions: Antipsychotic medications may be used to treat an enduring condition (non-acute, chronic, or prolonged). Monitoring must…

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 residents were free of chemical restraints for three of nine residents (R27, R32, R57) reviewed for anti-psychotic medication use in the sample of 35. Findings include: The facility's Abuse Policy dated 1-9-24 documents, Chemical restraints are not used. The facility's Psychotropic Medications Protocol Chemical Restraints dated 5-16-22 documents, Chemical restraints will not be used to limit or control resident behavior for the convenience of staff. 1. On 5/5/24 at 10:50 AM, R27 was in his room lying in bed. R27 stated he is doing ok. R27 was not displaying any behaviors. On 5/7/24 at 2:30 PM, V12 (Licensed Practical Nurse) entered R27's room to complete wound care. R27 was sleeping off and on throughout the treatment and V12 stated You've been sleepy today. R27 was cooperative with care and was not displaying any behaviors. R27's care plan, dated 2/27/24, documents R27 is on an antipsychotic. He takes Haloperidol (antipsychotic…

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 observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were followed and care planned for residents who are at a high risk for infection for two of seventeen residents (R27, R29) reviewed for Infection Control in the sample of 35. Findings include: The facility's Enhanced Barrier Precautions protocol sign (undated) documents Everyone must clean their hands, including before entering and when leaving the room. Provides and Staff must also wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use (Central Line, Urinary Catheter, Feeding tube, tracheostomy), Wound Care: Any skin opening requiring a dressing. 1. R27's Physician Order sheet, dated 5/8/24, documents R27 has an order for an indwelling urinary catheter to be changed monthly. This same order sheet documents R27 has wound treatment orders to be completed on the coccyx daily and R27's left second toe daily and…

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 document appropriate indications for use of an antipsychotic medications and initiate gradual dose reductions at least yearly for three of five residents (R27, R41, R61) reviewed for unnecessary medications in the sample of 27. Findings include: The Facility's Psychotropic Medication Policy revised 11/28/17, documents, Additionally, Antipsychotic medication may be indicated for use if: 1) Behavioral Symptoms present a danger to the resident or others; 2)Expressions or indications of distress that are significant distress to the residents: 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presented a danger or significant distress; and or 4)GDR (Gradual Drug Reduction was attempted, but clinical symptoms returned. 1. On 5/16/23 at 10:30 a.m., R27 was sitting in the family room with no behaviors observed. R27's MDS (Minimum Data Set) assessment 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 observation, interview and record review, the facility failed to label food items, dispose of outdated foods and wash hands when coming into the kitchen and after handling dirty dishes and before handling clean dishes. This has the potential to affect all 45 residents living in the facility. Findings: The document Food Labeling and Dating, dated 2/22 documents, Labeling and dating food is important to assure foods are used in a timely manner. Proper food labeling includes: Name of product, date stored and in some cases, the time of the day; the food must be labeled and dated if it is removed from its original container. The document Food Storage Chart, dated 2/22, documents, Use by dates printed on label by the manufacturer applies until the product is opened. Once opened, use the following time limits. After a food item is opened, it will be covered, labeled, the 'use by date' will be put on, initiated and stored. The day of opening/preparation counts as Day 1. Meats, Cottage Cheese, Salads - seven days;. On 2/28/22 at 9:55 AM, the refrigerator held one pan containing two…

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 observation, interview, and record review, the facility failed to revise a Care Plan with the development of a pressure ulcer, resident to resident altercation, significant weight loss, and ROM (Range of Motion) limitations for four of 15 residents (R17, R28, R40, R41) reviewed for Care Plans in the sample of 24. Findings include: The facility's Care Plan Process policy, dated 11/2017, documents, A comprehensive person-centered Care Plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs, while honoring resident rights to choice. This Care Plan shall include goals, measurable objectives, and interventions to meet identified resident needs. 1. The facility's Wound and Ulcer Policy and Procedure policy, dated 1/10/18, documents, When a resident is found to have a wound, a licensed nurse will complete ulcer, either on admission or during their stay, the following care interventions for staff involved in the resident's care are communicated via the resident Care Plan . 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.

Based on observation, interview, and record review, the facility failed to protect a resident from physical abuse by another resident. This has the potential to affect two of two residents (R28, R41) reviewed for abuse in the sample of 24. Findings include: The facility's Abuse Prohibition Policy, dated 3/15/18, documents, All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be verbal, sexual, physical, and mental abuse, including abuse facilitated or enabled through the use of technology or social media. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 02/28/22 at 10:41 AM, R41 was lying in her bed with V16 (Unit aide) at her bedside. V16 stated, I'm not really sure why (R41)…

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 interview and record review, the facility failed to follow operational policies and procedures regarding developing new interventions to prevent further physical abuse following an allegation of physical abuse for two of two residents (R28, R41) reviewed for abuse in the sample of 24. Findings include: The facility's Abuse Prohibition Policy, dated 3/15/18, documents, Prevention of Abuse: Appropriate interventions to address identified behaviors will be included on resident Care Plans, and reviewed as/when change occurs. These interactions will be communicated to the direct caregivers. The facility Report to the State Agency, dated 2/25/22, documents, This resident (R41) was involved in a resident to resident altercation with no injuries. On February 21, 2022, (R41) was at the nurses station asking staff to taker her home and stating her address repeatedly. (R41) is alert and oriented times one with confusion and requires staff intervention and frequent reminders of the date, year, and where the facility is located. (R41) also requires staff assistance for ADLs (Activities…

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 observation, interview, and record review, the facility failed to provide assistance with shaving for one of three residents (R40) reviewed for ADLs (Activities of Daily Living) in the sample of 24. Findings include: The facility's A.M. (Morning) Care policy, dated 4/2009, documents, Objective: To provide personal hygiene in the morning. Provide assist with shaving (both male and female). R40's MDS (Minimum Data Set) assessment, dated 2/8/22, documents, Functional Status: requires extensive assistance by one person for personal hygiene. On 02/28/22 at 11:01 AM, R40 was alert lying in bed. R40 had multiple long white hairs above R40's lip and on R40's chin and neck. R40 stated, I've been asking them for days to shave me. They keep saying they are going to do it, but they haven't. I don't like having long whiskers. On 03/01/22 at 12:11 PM, R40 was alert sitting up in her motorized wheel chair at the dining room table eating lunch. R40 stated, I still haven't gotten my whiskers trimmed. On 03/01/22 at 01:50 PM, V12 and V15 (Both CNAs-Certified Nursing Assistants) exited R40'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 record review and interview, the facility failed to act upon a significant weight loss, notify the Physician and implement further weight loss prevention interventions in a timely manner, for one of two residents (R36) reviewed for weight loss, in a sample of 24. Findings include: The facility Policy, titled Weight Management Policy and Procedure (Revised 2/2016), documents, Each resident will be weighed at least once per month on a predetermined schedule. All residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. The Policy further documents, At least monthly, resident weights will be compared to prior weights to identify any significant, severe or insidious weight changes. The Weight and Vitals Exception Report will be reviewed weekly by dietary staff to determine significant weight changes. Parameters of a significant weight change per OBRA (Omnibus Budget Reconciliation Act) guidelines will be used. Weight loss that occurs quicker…

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, record review and interview, the facility failed to ensure a indwelling catheter bag and tubing remained off the floor for one of one residents (R36) reviewed with an indwelling catheter, in a sample of 24. Findings include: The facility policy, titled Catheter Protocol (dated 2/01/10), documents 7. The collection bag for catheters shall be emptied at least every shift. Care shall be taken to avoid contact of the drainage tube with anything that could contaminate it. On 02/28/22 at 11:37 AM, R36 was lying in bed, with his suprapubic catheter bag connected to the bottom of the bed frame. R36's bed was in the lowest position, close to the floor, and the catheter bag was resting on the floor. On 03/01/22 at 09:38 AM, R36 had been returned to the nurses' station from the Therapy Department, as R36 was propelled in his wheelchair down the hall, his catheter bag and tubing was dragging on the floor. On 03/02/22 at 12:14 PM, R36 was propelling himself from the dining room back to his room after lunch. R36's catheter tubing was coiled and dragging under his…

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 observation and interview, the facility failed to empty a personal commode in a resident room that was causing odors for one of three residents (R28) reviewed for ADLs (Activities of Daily Living) in the sample of 24. Findings include: On 03/01/22 at 12:41 PM, R28 was alert sitting up in her recliner in her room. R28 had a commode located immediately to R28's left side. A foul urine like smell was noted in R28's room. R28 stated, I don't use the restroom to go to the restroom, I use this commode. The staff hardly ever dump it for me. Can you smell it? It's like this all the time. No one from third shift dumped it and no one has dumped it this shift either. R28 lifted the commode lid. The commode container was filled half the way up with a dark brown green liquid, and more odor was let out at that time. R28 stated, It gets so full that when I wipe myself, my hands end up touching what's in the commode. It's disgusting. On 03/01/22 at 01:39 PM, R28 was lying back in her recliner. R28's room continued to have a foul urine odor. R28 stated, The commode was just emptied. 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.