Bell Minor Home, The

In the surveyor’s words

From the most serious findings on record at Bell Minor Home, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Mar 30, 2025

  Based on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure that two of 40 sampled residents (R) (R159 and R9), medical providers, and family were timely notified of a change in condition. R159's medical provider was not notified of any changes in the resident's condition, including the lack of pedal pulses. Additionally, R159's family was not made aware of the resident's condition from 8/28/2024 until 9/7/2024. On 9/7/2024, R159's family was concerned about the resident's condition and requested that the resident be transferred to the hospital; however, the facility denied the request. […]

• Immediate jeopardy, isolatedF600Mar 30, 2025

  Based on the interviews, record review, and a review of the facility's policies titled Abuse Prevention Policy, Pressure Ulcer Treatment, and Prevention of Pressure Ulcers, the facility failed to ensure residents were free from abuse and neglect for three of six residents (R) (R159, R9, and R360) reviewed for abuse and neglect. (1) The facility neglected to emergently transfer R159 to the hospital per the family's request and failed to notify R159's physician after a change in condition, which resulted in a delay in treatment. (2) The facility failed to notify R9's wound treatment provider of the worsening of the resident's diabetic ulcer. (3) R360 was physically abused by her roommate (R46), who had a history of abusing other residents. […]

• Immediate jeopardy, isolatedF658Mar 30, 2025

  Based on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure the nursing staff used their clinical skills and judgement to identify and notify the resident's medical provider of the worsening of skin condition for one of three sampled residents (R) (R159). On [DATE] and [DATE], R159 had a change in condition when pedal pulses were unpalpable; however, nursing staff did not identify this as a change in condition, and the resident's medical provider was not notified. […]

• Immediate jeopardy, isolatedF686Mar 30, 2025

  Based on observation, interview, record review, and a review of the facility's policies titled Prevention of Pressure Ulcers and Pressure Ulcer Treatment, the facility failed to ensure that three of three sampled residents (R) (R104, R2, and R307) did not develop facility-acquired pressure ulcers. The facility failed to prevent the development of significant pressure ulcers for two of the three residents reviewed (R104 and R2). The facility failed to provide oversight, ensuring pressure ulcer assessments were completed, and ensure pressure ulcer treatment was provided in a timely manner and per the physician's orders. 1. R104 did not have preventive interventions in place before [DATE], when a pressure ulcer to the sacrum was identified. […]

• Immediate jeopardy, isolatedF835Mar 30, 2025

  Based on interviews, facility policy review, and job description review, the facility administration failed to use resources to ensure residents attained and maintained their highest physical well-being. The facility's Administrator and the Director of Nursing (DON) failed to identify failures from nursing and other facility staff, which caused the actual harm and/or death of residents. 1. The facility's administration failed to ensure that residents' physicians and/or other medical providers were notified after R159 and R9 had changes in conditions related to the worsening of their skin conditions. Cross Reference F580-J 2. The facility's administration failed to ensure residents were free from neglect and abuse. […]