Beaumont Rehabilitation And Healthcare Center
BEAUMONT REHABILITATION AND HEALTHCARE CENTER in ANDERSON, IN — inspection on July 2, 2024.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 6/28/24 at 1:36 p.m., CNA 15 indicated, approximately three weeks ago, Resident 81 reported concerns due to a lack of large portions sizes.
During that time, she was able to get her additional food.
She did not typically have time to write out the grievance forms but she reported concerns verbally to the nurse, unit manager, and the SSD.
Review of facility grievances lacked indication of the concern related to portion sizes.
During an interview on 6/28/24 at 4:11 p.m. , CNA 19 indicated residents on the intermediate units frequently received dislikes on their meal trays.
Running to the kitchen delayed the aides to complete their tasks such as passing other meal trays and providing care.
Staff who had concerns reported to them should have completed a grievance form or reported the concern to the Administrator so he could complete the grievance form.
During an interview on 6/28/24 at 3:23 p.m., the SSD indicated the grievance log contained all facility grievances, completed and unresolved, from 1/1/24 to 6/28/24.
During an interview on 7/2/24 at 2:19 p.m., the SSD indicated she had reviewed the grievance log and did not have any grievances of her own or any provided to her regarding the above mentioned concerns that were reported to staff members.
A current, undated, facility policy titled Grievances and Concerns, provided by the DON on 7/1/24 at 11:29 a.m., indicated the following: .Policy . It is the Policy of this Facility to thoroughly investigate all Resident and family grievances/concerns including but not limited to his/her treatment, medical care . etc.
The resident/family has a right to file a grievance and can do so without fear of reprisal or mistreatment.
Procedure: . 2.
Any staff member may assist a Resident or family member in completing the Facility form. 3.
Completed Grievance/Concern Forms will be given to the Social Service Department.
The Social Service Department will route the Grievance/Concern Form to the appropriate department within 24-48 hours. 4. A prompt investigations will be completed and documented by the appropriate staff member on the facility's Grievance/Concern Form . 6.
The Social Service Director will be responsible for logging all Resident and family Grievances in the Facility Grievance Log. 7.
Within 5 working days of the date the Grievance/Concern Form was filed, the Resident and/or family member shall be informed orally of the results of the investigation.
Copies of the completed Grievance/Concern Form may be given to Residents and/or family members as deemed appropriate by the Facility management 3.1-7(a)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
did speak to the Administrator about the allegation.
She thought it was about flailing arms during care.
A current, 5/12/23, facility policy titled, Abuse and Incident Reporting to IDOH , which was provided by the DON on 7/1/24 at 10:55 a.m., indicated the following: It is the policy of this facility to report and submit abuse and incidents to the Indiana State Department of Health in compliance with federal regulations .Time frames for reporting: Immediately, but no later than 2 hours-suspicion of a crime with serious bodily injury or allegations of abuse.
This citation relates to complaint IN00436566. 3.1-28(c)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview on 6/27/24 at 11:40 a.m., the DON indicated Resident E was not placed on 15-minute monitoring following the 6/14/24 resident to resident altercation.
During an interview on 6/27/24 at 3:03 p.m., QMA 29 indicated Resident E wandered and entered other resident's rooms.
A current, 2/29/21, facility policy titled Behavior Crisis, provided by Corporate Nursing Consultant 7 on 6/28/24 at 1:00 p.m., indicated the following: .Behavior Crisis: is defined as a situation in which the resident is considered to be a significant danger to self or others.
The crisis may or may not have been exhibited in the past .
- Implement measures to provide safety to residents and others as pertinent .
A current, 5/12/23, facility policy titled Abuse and Incident Reporting to IDOH, provided by the DON on 7/1/24 at 10:55 a.m., indicated the following: .Instructions for Submitting an Incident Report . i.
Preventive measure taken while the investigation is in process .Interventions implemented or corrective action plan This citation relates to complaint IN00436913 and IN00436778. 3.1-28(d)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview, on 6/27/24 at 2:53 p.m., the MDS Coordinator indicated her team utilized the Resident Assessment Instrument (RAI) manual online for properly managing the MDS tasks.
The work was split up between herself and a co-worker.
She indicated the above listed assessments were completed late.
According to the current RAI manual, retrieved from https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, on 7/3/24 at 10:01 a.m., indicated the following: .
The Quarterly MDS completion date must be no later than 14 days after the assessment reference date (ARD) . 3.1-31(d)(3)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview, on 6/27/24 at 2:53 p.m., the MDS Coordinator indicated the assessment transmission task was split between herself and her offsite corporate consultant.
This discharge assessment was missed in error during the transmission process.
Once this error was discovered, the assessment was transmitted electronically immediately.
She utilized the online Resident Assessment Instrument (RAI) manual for guidance as the MDS Coordinator.
Review of the current the RAI manual, retrieved from https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, on 7/3/24 at 10:01 a.m., indicated the following: .
The Discharge assessment transmission date is no later than the MDS completion date plus 14 days
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
care plan meetings since January 2024 or prior.
a.m., indicated Care Plan meeting will be held within 7 days of the completion date [MDS] .
Meetings will occur on set day and time (no excuse for not having a care plan meeting). 3.1-35(c)(1)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview on 6/28/24 at 3:58 p.m., LPN 18 indicated documentation should not have been left blank on several shifts in the treatment administrator record (TAR).
Wound treatments should have been completed as ordered.
There was no way to show the treatment had been administered when it was left blank.
During an interview on 6/28/24 at 4:50 p.m., the DON indicated treatment/wound care orders should have been completed as ordered by the physician to promote healing of a wound.
A current facility policy, dated 12/1/23 and titled Physician Services and Orders, provided by Corporate Nurse Consultant 7 on 7/1/24 at 3:07 p.m., indicated the following: .POLICY: It is the policy of the facility to ensure that the medical care of each resident is supervised by a physician.
The facility will provide care and services related to physician services in accordance with State and Federal regulations. PROCEDURE: . 11.
All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the the resident's medical record during that shift 3.1-37(a)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During a wound observation on 6/27/24 at 2:38 p.m., LPN 12 and CNA 13 entered the resident's room for wound care. LPN 12 used gloved hands and removed a moderately soiled dressing, dated 6/25/24, from the resident's right buttock.
The nurse confirmed the dressing was dated 6/25/24.
The dressing had not been changed on 6/26/24.
During an interview on 6/28/24 at 3:58 p.m., LPN 18 indicated the resident's clinical record lacked indication of the ordered treatment being completed on several shifts in the treatment administrator record (TAR). It was unacceptable to not complete the treatments as ordered.
There was no way to show the treatment had been administered when it was left blank.
During an interview on 6/28/24 at 4:40 p.m., the DON indicated treatment/wound care orders should have been completed as ordered by the physician to promote healing of a wound.
A current facility policy, dated 11/2023 and titled Treatment/Service to Prevent/Heal Pressure Ulcers, provided by the DON on 7/1/24 at 1:45 p.m., indicated the following: .INTENT: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. PROCEDURE: 1.
The facility will ensure that based on the comprehensive Assessment of a resident: . b. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing 3.1-40(a)(2)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview on 6/27/24 at 12:18 p.m., LPN 32 indicated the nurse on staff was responsible for checking the oxygen concentrator and ensure they were set as ordered by the physician.
During an interview on 7/1/24 at 2:58 p.m., the DON indicated the expectation for the nursing staff is to ensure the physician orders were being followed.
Review of a current facility policy, dated 12/1/23 and titled Physician Services and Orders, provided by Corporate Nurse Consultant 7 on 7/1/24 at 3:07 p.m., indicated the following: .11.
All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during the shift 3.1-47(a)(6)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview, on 6/26/24 at 10:19 a.m., the Family Tree Unit Manager indicated the expectation
shift.
She was not sure why this task was not being completed as expected.
During an interview, on 6/26/24 at 10:13 a.m., the DON indicated all nurses were to sign the narcotic counts sheets for persons taking over the cart and the person leaving the cart. A lack of signature and incomplete counts was a risk for drug diversion.
A current, undated, facility policy titled, Narcotic Nurse to Nurse Reconciliation, provided by the DON on 7/1/24 at 3:45 p.m., indicated the following: .
When keys to secured storage area occur between 2 applicable licensed staff there will be a count that is completed to validate the items are accurate Each reconciliation will require: 1.
Two signatures (on coming and off going) . 3.1- 25(b)(3)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
the date opened on the medication container when the medication has a shortened expiration date
3.1-25(j) 3.1-25(k)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview, on 6/26/24 at 10:14 a.m., the DON indicated she had started Performance Improvement Plan (PIP) for an identified concern at the facility, such the failure of nurses to sign in and out to acknowledge reconciliation of the narcotic medication at the change of shift.
She indicated the completion date for her PIP was 9/13/24.
A current facility PIP guide, provided by the DON on 6/26/24 at 10:14 a.m., indicated the start date as 6/13/24 for nurses not signing in and out on the record of accepting narcotic responsibilities.
The plan or tasks to be completed included a review of sign in/sign out sheets, a staff in-service, and Clean Fridays audits were to be initiated.
The staff in-service was held on 6/13/24.
The facility nursing staff was verbally re-educated on 6/26/24.
During an interview, on 7/2/24 at 3:00 p.m., the DON indicated she did not have any audit tools, additional documentation, or evidence to provide to support the implementation of approaches listed on the PIP guidance tool.
The Family Tree Unit Manager was doing reviews of the medication cart narcotics binders on Fridays, but the DON had not created the Clean Fridays tool as of yet.
She indicated on the review dates listed, she would analyze the audit tools and complete the sections measuring the outcome of the action plan.
Review of a current facility policy, titled, Quality Assurance and Performance Improvement, dated 11/23, and provided by the Administrator following the Entrance Conference on 6/24/24, indicated the following: .
Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section.
This may include but is not limited to systems and reports demonstrating system identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities .
Cross reference F-F755.
Cross reference F-F761. 3.1-52(b)(2)
155005 07/02/2024
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
During an interview on 6/27/24 at 4:14 p.m., CNA 13 indicated she was uncertain what PPE should have been worn for EBPs and when EBPs should have been utilized or implemented.
She had just assisted with wound care in Resident 70's room with an EBP sign on the door.
She had not worn a gown during the wound care.
She then read the EBP sign on the door and indicated she should have worn a gown in addition to her gloves during the wound care for Resident 70.
During an interview on 6/27/24 at 4:19 p.m., LPN 12 indicated both Resident 70 and Resident 83 had orders for EBPs.
She had not worn a gown during wound care for Resident 70 and Resident 83 on this date. EBPs required a gown and gloves use for high contact care such as wound care.
During an interview on 7/1/24 at 2:50 p.m., the DON indicated EBPs should have been followed by all staff during wound care.
The facility followed physician's orders as it was a nursing standard of practice.
A current undated facility policy, titled Enhanced Barrier Precautions, provided by Corporate Nurse Consultant 7 on 7/1/24 at 8:45 a.m., indicated the following: Policy Statement .
Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms .
Policy Interpretation and Implementation 1.
Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a) Gloves and gown are applied prior to performing the high contact resident care activity . 3) Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . h) wound care 3.1-18(b)(2)
During a wound observation and interview on 6/27/24 at 2:38 p.m., LPN 12 and CNA 13 entered Resident 70's Enhanced Barrier Precaution room with the sign visible to the left side of the door along with the personal protective equipment canister.
They both performed hand washing, donned gloves, then LPN 12 set everything up for wound care. LPN 12 used gloved hands and removed the moderately soiled dressing from the resident's right buttock. CNA 13 was there to assist with the wound care.
Neither LPN 12 nor CNA 13 donned a gown.
Throughout wound care, both LPN 12 and CNA 13 leaned up against the resident's mattress with their unprotected clothing.
The wound bed on the right buttocks was covered with slough and consistent with the last wound assessment measurements and description.
Resident 70's clinical record was reviewed on 6/26/24 at 4:20 p.m. A current physician order, dated 4/25/24, included the following: Enhanced Barrier Precaution Isolation for high contact resident activity.
Gown and glove use was required for 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), or wound care every shift.
During an observation on 6/24/24 at 11:59 a.m., Resident 83's room had an Enhanced Barrier Precaution sign noted to the left of her door.
Upon entry to the room, the Personal Protective Equipment (PPE) canister was located behind the door in a canister.
Resident 83's clinical record was reviewed on 6/27/24 at 10:22 a.m. A current physician's order, dated 4/25/24, included the following: Enhanced Barrier Precaution Isolation for high contact resident activity.
Gown and glove use was required for 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), or wound care every shift.
During a wound observation on 6/27/24 at 3:39 p.m., LPN 12 approached Resident 83's room with an Enhanced Barrier Precaution sign hung on the left side of the resident's door.
The sign indicated high contact care such as wound care required hand hygiene, a gown, and gloves.
Upon entry to the resident's room, LPN 12 washed her hands.
She donned gloves for wound care but did not wear a gown for the wound care.
Upon removal of the dressing, the wound to the left lateral foot was open and slightly smaller than the tip of an eraser with a discernable depth. A small amount of serous drainage was noted on the removed dressing.
155005
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 155005 B.
Wing 07/02/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.