Benedictine Health Center Innsbruck

In the surveyor’s words

From the most serious findings on record at Benedictine Health Center Innsbruck, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Nov 8, 2024

  Based on interview and document review, the facility failed to follow physician orders to provide a resident nothing by mouth for 1 of 5 residents (R1) reviewed for diet orders. This resulted in an immediate jeopardy (IJ) for R1 when he was provided with a pastry, orange juice and coffee by staff, and later became hypoxic and was sent to the hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 11/4/24 at 8:45 a.m. when nursing assistant (NA)-A provided R1 with a pastry, orange juice and coffee. The administrator and director of nursing (DON) were notified of the IJ on 11/8/24 at 2:48 p.m. […]

• Actual harm, isolatedF686Aug 20, 2026

  Based on interview and document review, the facility failed to comprehensively assess and implement an effective turning and repositioning program to prevent pressure ulcer development; failed to ensure the care plan was updated with new interventions to ensure implementation; and failed to ensure a developed pressure ulcer was accurately tracked and monitored in the medical record for 1 of 3 residents (R2) reviewed for pressure ulcer care. R2 needed physical assistance with repositioning, however, no consistent repositioning program was implemented and R2's care plan was not updated as she became more at risk for pressure ulcer development. R2 then developed multiple, avoidable stage II pressure injuries on her coccyx which constituted actual harm. […]

• No harm, potential for more than minimal, widespreadF880May 15, 2025

  Based on observation, interview, and document review the facility failed to ensure proper hand hygiene practices for 2 of 2 residents (R62, R59) observed during personal cares. In addition, the facility failed to ensure appropriate room assignment for 6 of 10 residents (R26,R23,R136,R74,R12,R11) reviewed for transmission based precautions (TBP). Also, the facility failed to ensure consistent and appropriate personal protective equipment (PPE) use for 5 of 10 residents (R11,R12,R73,R76, R59) reviewed for TBP and staff handling soiled laundry. […]

• No harm, potential for more than minimal, widespreadF812Aug 15, 2024

  Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly stored, labeled, and dated and disposed after expiration date. Furthermore, the facility failed to ensure the use of hair restraints. This deficient practice had the potential to affect all residents who receive food from the kitchen. Findings include: Food Storage: During the initial kitchen observation on [DATE] at 12:06 p.m., the refrigerator contained the following: a gallon of 1% milk with a best by date of [DATE] and the dietician stated needed to be thrown out. […]

• No harm, potential for more than minimal, widespreadF812Sep 14, 2023

  Based on observation, interview, and document review, the facility failed to ensure foods were labeled and dated in the main kitchen and kitchenettes, and failed to ensure the use of hair restraints during food preparation. This had the potential to affect all residents, family, and staff who received food from the kitchen. Findings include: During the initial kitchen tour with the director of dining services (DDS) on 9/11/23 at 12:11 p.m., observed the following: Kitchen Reach in Freezer: 1 package of four chicken breasts with a used by date 8/14. DDS took the items out of the freezer and threw the items away. 1 package of undated and unlabeled meat DDS stated looked like country fried steak. […]