Beaver County Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure fall interventions were individualized and revised after a fall for residents assessed as a high risk for falls for two (#13 and #15) of two sampled residents reviewed for individualized care plans. The administrator identified 35 residents resided in the facility Findings: An undated facility Accidents policy, read in part, The intent of this policy is to ensure this facility provides an environment that is free from accidents hazards over which the facility has control and provides supervision and assistive devices are provided for each resident to prevent avoidable accidents. This includes: a. Identifying hazards and risk, b. Evaluating and analyzing hazards and risk, c. Implementing interventions to reduce hazard, and d. Monitoring for effectiveness and modifying interventions when necessary. The policy also read, Individualized, person centered interventions will be implemented, including adequate supervision assistive devices, to reduce…

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 record review and interview, the facility failed to ensure RN coverage for eight consecutive hours, seven days per week. The administrator identified 35 residents resided in the facility. Findings: A PBJ Staffing Report, dated 07/01/24 through 09/30/24, did not document any RN hours for 07/06/24, 07/07/24, 07/12/24, and 07/13/24. A Nurses Schedule, dated July 2024, were reviewed and schedule did not document RN coverage for 07/06/24, 07/07/24, 07/13/24, and 07/14/24. On 12/11/24 at 11:03 a.m., the administrator was asked what the facility policy for staffing an RN eight hours a day seven days a week. They stated the facility should have RN coverage eight hours a day, seven days a week. The administrator was then asked to review the nurses schedule for 07/06/24, 07/07/24, 07/13/24, and 07/14/24, then asked if the facility had RN coverage for those four days. They stated No.

Based on observation, record review, and interview, the facility failed to ensure a medication rate of less than 5%. A total of 25 opportunities were observed during the medication pass with two errors identified. The total medication error rate was 8% related to two medications held without physician orders for parameters to hold medications for one (#11) of three sampled residents observed during medication pass. The administrator identified 35 residents resided in the facility. Findings: A Adverse Consequences and Medication Errors policy, revised April 2024, read in part, a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders. Resident #11 had diagnoses which include hypertension, edema, and dementia. A Order Summary, dated 12/10/24, documented an order for quinapril [hypertensive medication] 10mg by mouth daily and Lasix (furosemide) (diuretic medication) 10mg daily for edema. There was no documentation in the order directions for holding either medication if the blood pressure reading was…

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, records review, and interview, the facility failed to ensure staff washed their hands between residents while assisting dependent residents with feeding for three (#11, 19, and #35) of three sampled residents observed during dining. The DON identified six residents required assistance during meals. Findings: The facility's Handwashing/Hand Hygiene policy, revised 08/2015, read in part, Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: The policy also read, Before and after assisting a resident with meals. 1. Resident #11 was admitted on [DATE] with diagnoses which included unspecified dementia and delusional disorder. Resident #11's quarterly assessment, dated 09/30/24, documented the resident's cognition was significantly impaired and required supervision or touching assistance with eating. 2. Resident #19 was admitted on [DATE] with diagnoses which included Alzheimer's disease…

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 ensure a resident's physician and family representative was notified of inappropriate behaviors for one (#35) of 16 sampled residents who were reviewed for notifications. The DON identified 35 residents resided in the facility. Findings: Resident #35 was admitted on [DATE] with diagnoses which included legal blindness, adjustment disorder with depression, and anxiety disorder. Resident #35's quarterly assessment, dated 11/04/24, documented the resident's cognition was mildly impaired. A progress note, dated 12/08/24, read in part, Reported by CNA that neighbor was in dining room this morning at breakfast sitting at the table and stood up and pulled [their] pants down and peed on the floor. On 12/10/24 at 10:03 a.m., Resident #35's POA stated they were not notified of the incident on 12/08/24. On 12/12/24 at 11:33 a.m., LPN #2 was asked who and when was someone contacted when a resident had a behavior like pulling pants down in front of others 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, record review, and interview, the facility failed to ensure the facility policy to change O2 tubing was followed for one (#5) of one sampled resident reviewed for O2 tubing. The DON identified 12 residents had physician orders for O2 therapy. Findings: The facility's Departmental (Respiratory Therapy)-Prevention of Infection policy, revised 11/2011, read in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff. The policy also read, Change the oxygen cannula and tubing every (7) days, or as needed. Resident #5 was admitted on [DATE] with diagnoses which included Bartter's syndrome, chronic obstructive pulmonary disease, and anxiety disorder. Resident #5's physician orders, dated 06/19/24, documented O2 at 2 liters via nc and as needed for SOB and HS. On 12/09/24 at 1:35 p.m., Resident #5's O2 tubing was observed labeled in pen on white tape and dated 11/01/24. 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, record review, and interview, the facility failed to ensure a diuretic and blood pressure medication were administered per physician's orders for one (#11) of three sampled residents observed during medication pass. The administrator identified 35 residents resided in facility. Findings: A Adverse Consequences and Medication Errors policy, revised April 2014, read in part, a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications. It also read in part, examples of medications errors include: omission- a drug is ordered but not administered. Resident #11 had diagnoses which included hypertension, edema, and dementia. A Order Summary dated 12/10/24, documented order for quinapril (hypertensive medication)10mg by mouth daily and Lasix (furosemide) (diuretic medication) 10mg daily for edema. There was no documentation in the order directions for holding either medication if the blood pressure reading was below certain parameters. On 12/10/24 at 8:25 a.m.,…

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 record review, observation, and interview the facility failed to: a. ensure temperatures were obtained and foods were held at 135 degrees on the holding table, and b. ensure dishes and utensils were cleaned/sanitized to prevent food borne illness. The Administrator identified 40 residents who received their meals from the kitchen. Findings: A policy titled, Food Temperatures, review date 05/01/22, read in part, . Ensure food is served at a safe temperature to prevent food-borne illness .Hot Foods should be maintained at a minimum of 135 degrees F . A policy titled, Dish Washing, review date 05/01/22, read in part, .Low Temperature Dishwasher(chemical sanitization): Wash-120 degrees F and Final Rinse-50 ppm .hypochlorite .on dish surface in final rinse .The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines . A Monitoring Record, dated 07/01/22 to 07/20/22, documented on 07/05/22, 07/09/22 and 07/10/22 holding table temperatures were…

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 record review, observation, and interview, the facility failed to report and investigate an injury of unknow origin for one (#24) of one sampled resident reviewed for abuse. The Resident Census and Conditions of Residents, dated 07/19/22, documented 40 residents resided in the facility. A policy titled, Abuse, Neglect, Mistreatment And Misappropriation of Resident Property, approved 05/26/21, read in part, .It is the policy of this facility that reports of abuse ( .including injuries of unknown source .) are promptly and thoroughly investigated .REPORTING AND RESPONSE .The facility will ensure that all alleged violations involving abuse .including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made .in accordance with State law . Findings: Resident #24 was admitted with diagnoses of unspecified dementia without behavioral disturbance, tremors and hypertension. Resident #24's admission assessment, dated 06/08/22, documented the resident's cognition was moderately impaired. On 07/19/22 at 10:39 a.m., Resident #24'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.

Based on record review, observation, and interview the facility failed to assess, monitor and intervene for an injury of unknown origin for one (#24) of one sampled resident reviewed for injury. The Resident Census and Condition report, dated 07/19/22, documented 40 residents resided in the facility. Findings: Resident #24 was admitted with diagnoses of unspecified dementia without behavioral disturbance, tremors and hypertension. Resident #24's admission assessment, dated 06/08/22, documented the resident's cognition was moderately impaired. On 07/19/22 at 10:39 a.m., Resident #24's right hand was observed swollen. The swelling was observed to start above the resident's right wrist and continued to their fingers. There was no documentation in the resident's clinical record regarding an incident that happened to the resident's right hand/wrist. On 07/20/22 at 2:28 p.m., the administrator was asked if Resident #24 had an injury to their right hand. They stated they weren't aware of the resident's hand and didn't see anything documented. On 07/20/22 at 2:30 p.m., the DON and LPN #2…

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 record review, observation, and interview, the facility failed to ensure FSBS was obtained prior to administering sliding scale insulin for one (#41) of one sampled resident reviewed for insulin administration. The MDS coordinator identified six residents received insulin. Findings: A policy titled, Resident-Centered Medication Pass, review date 05/01/22, read in part, .Purpose: Allow administration of medications according to a resident's schedule/routine while ensuring the safe and accurate administration of all medications .Exceptions to the Resident-Centered Medication Pass Policy/Procedure: Insulin should be administered consistently each day . Resident #41 was admitted with diagnosis of diabetes mellitus. A Physician's Order, dated 03/17/18, documented to administer Novolog Solution eight units for a FSBS between 151-200. A Physician's Order, dated 06/22/21, documented to obtain FSBS before meals and at bedtime. Resident #41's quarterly assessment, dated 07/04/22, documented the resident's cognition was moderately impaired. It documented the resident received seven…

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 record review and interview, the facility failed to follow up on a physician's response on a GDR for one (#17) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 07/19/22, documented four residents received antipsychotic medications. Findings: Resident #17 was admitted with diagnoses of schizoaffective bipolar disorder and dementia with behavioral disturbance. A Physician's Order, dated 10/13/21, documented the resident was to receive Zyprexa once a day. A Medication Regimen Review, dated 01/07/22, read in parts, .Could a reduction be tried for the Zyprexa . The physician's response read in parts, .defer to .psych provider . There was no documentation in the resident's clinical record the GDR was followed up on. Resident #17's quarterly assessment, dated 05/23/22, documented the resident's cognition was intact. It documented the resident received seven antipsychotic medications in seven days. It documented a GDR hadn't been attempted and there was no documentation of a contraindication. On 07/20/22 at 3:27 p.m.,…

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.