Bellbrook

In the surveyor’s words

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

• Actual harm, isolatedF684Dec 17, 2024

  This citation pertains to intake: MI00148291. Based on interview and record reviews the facility failed to timely notify the Physician and/or practitioner of an identified change of condition and failed to monitor/assess the resident once the change of condition was identified for one (R140) of one resident reviewed for a change of condition, resulting in a delayed notification to the physician and delayed interventions and care/treatment. Findings include: A review of a complaint submitted to the State Agency (SA) included concerns of the facility staff to have failed to properly assess and seek appropriate treatment following a change in R140's condition. […]

• No harm, potential for more than minimal, widespreadF812Dec 17, 2024

  Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 12/15/24 between 8:50-9:35 AM, during an initial tour of the kitchen, the following items were observed: In the walk-in cooler, there was a pan of cooked corned beef, uncovered and undated. The Internal temperature of the corned beef ranged from 99-102 degrees Fahrenheit. When queried at that time, Dietary Staff C stated the corned beef had been cooked sometime this morning. When queried about a cooling log, Dietary Staff C checked the log and stated that the corned beef had not been placed on the cooling log. […]

• No harm, potential for more than minimal, widespreadF812Dec 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure personal cell phones were not stored in the food preparation area, failed to ensure food items were discarded after the use-by dates, and failed to maintain kitchen equipment per the manufacturer's recommendations. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include: During an initial tour of the kitchen on 12/12/22 between 8:30 AM-9:15 AM with Certified Dietary Manager (CDM) A, the following observations were made: There were 2 cell phones and chargers on the food preparation counter across from the ovens. […]

• No harm, potential for more than minimal, widespreadF880Sep 14, 2021

  Based on observation, interview and record review, the facility failed to ensure adequate infection control practices including, 1) appropriate screening of visitors and staff; 2) properly utilize personal protective equipment (PPE); and 3) implement proper hand hygiene per Centers for Disease Control and Prevention (CDC) guidance for R15. This deficient practice had the ability to affect all 34 residents in the facility. Findings include: On 9/12/21 at 9:59 AM, an isolation cart with three drawers was observed in the hallway outside a room with a sign that read in part, - STOP - Full PPE Required beyond this point: 14-Day Isolation . Preferred PPE - Use N95 or Higher Respirator . […]

• No harm, potential for more than minimal, patternF760Dec 14, 2022

  This citation pertains to Intake MI00130893 Based on interview and record review, the facility failed to prevent a significant medication error for one (R189) of one resident reviewed for cardiac medications resulting in R189 missing five consecutive doses of an antiarrhythmic medication. Findings include: Review of the closed record revealed R189 was admitted into the facility on [DATE] with diagnoses that included: atrial fibrillation, heart failure and arthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R189 was cognitively intact and required the extensive assistance of staff for activities of daily living (ADL's). Review of R189's hospital discharge instructions dated 12/29/21 revealed in part, .Your primary diagnosis was: Paroxysmal atrial fibrillation . […]