Beautiful Savior Home

In the surveyor’s words

From the most serious findings on record at Beautiful Savior Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Dec 13, 2024

  Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) met one of the qualifications for a Certified Dietary Manager (CDM) by having an approved certification for food service management and safety from a certifying body, an associate's degree in food service management or hospitality, or had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management. This practice potentially affected all residents. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2024

  Based on observation and interview, the facility failed to ensure condiments were stored properly, clean grease and food from condiment and spice containers, clean grease build up from kitchen surfaces including the stove and oven, remove build-up of soap or other substances from soap dispensers, a soap dish, and dish washing machine trays, and to ensure trays and food containers were not stored on surfaces that were chipped and therefore unable to be sanitized. This practice potentially affected all residents who ate food from the kitchen. The facility census was 76 residents. 1. Observation on 12/05/24 from 9:31 A.M. to 12:55 P.M. showed: -At 9:31 A.M. bits of debris were all over the kitchen floor, most of which were one-half inch and smaller, with a few bits larger. […]

• No harm, potential for more than minimal, widespreadF880Dec 13, 2024

  Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices for three sampled residents (Resident #58, #27, and #74) who was on Enhanced Barrier Precautions (EBP - refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove during high contact resident care activities) failed to use adequate hand hygiene during incontinence care for (Resident #58); failed to ensure infection control was maintained during wound care for one sampled resident(Resident #2); failed to perform proper hand hygiene during cares for one sampled resident (Resident #74); and failed to ensure yearly tuberculosis (TB - a communicable disease that affects especially the lungs,… […]

• No harm, potential for more than minimal, widespreadF812May 5, 2023

  Based on observation and interview, the facility failed to remove a buildup of dust on the ceiling above the food preparation table; to remove a buildup of food debris and dust from under the six burner stove, the steam table and the food preparation table; to remove a heavy buildup of grease and burnt-on food from the metal grates that sit above the actual gas burners; and to maintain the gaskets (a material such as rubber or a part used to make the area between two pieces of a material resist the flow of fluid such as air or water) of the reach-in refrigerator in good repair. This practice potentially affected all residents. The facility census was 87 residents. 1. […]

• No harm, potential for more than minimal, widespreadF867May 5, 2023

  Based on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding infection control monitoring and tracking of infections in the facility which potentially affected all residents in the facility. There were 19 residents in the sample and the facility census was 87 residents. Record review of the Infection Surveillance-Overview from the facility's Infection Prevention and Control Manual dated 2020 showed, -Data Analysis will assist the facility in: --Determining the origin of infection. --Comparing current and past infection control surveillance. --Comparing the reported incidence of infections by type and location. […]