Boonespring Transitional Care Center, LLC

In the surveyor’s words

From the most serious findings on record at Boonespring Transitional Care Center, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Feb 16, 2024

  Based on observation, interview, and review of the facility's policies, it was determined the facility failed to provide services for a safe, clean, comfortable, sanitary, and homelike environment for thirty-seven (37) of forty-eight (48) sampled residents. Facility census was one-hundred twenty-nine (129). Observation on 02/14/2024 revealed there was a strong urine odor on two (2) of two (2) sofas on the 1200 Unit and a strong urine odor on one (1) of four (4) armchairs on the 1400 Unit. The findings include: Review of the facility's policy titled, Guidelines to Good Housekeeping, revision date 02/28/2003, revealed the facility was to provide an optimum environment for the staff, resident, and visitors. […]

• No harm, potential for more than minimal, patternF656Feb 16, 2024

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to develop and/or implement comprehensive care plans for five (5) of forty-eight (48) sampled residents, Resident #4, #89, #105, #106, and #229. 1. Resident #229's care plan had interventions to monitor the resident for altered cardiopulmonary status, complete respiratory evaluations as needed, notify the physician of significant changes, have the resident wear oxygen as ordered, and for staff to encourage the resident to refrain from smoking. However, the night of 02/04/2024 the resident experienced an untoward respiratory event which was not documented, and the physician was not notified. In addition, the resident was not wearing his/her oxygen. […]

• No harm, potential for more than minimal, patternF880Feb 16, 2024

  Based on observation, interview, and review of the facility's policy, it was determined the facility failed to sanitize one (1) of four (4) mechanical lifts between resident use on the first floor. The findings include: Review of the facility's policy, Infection Control Transmission Based Precautions (Airborne, Contact, Droplet) All Staff, last revision date 09/2023, revealed Standard Precautions would be used regardless of the residents' suspected or confirmed infection status. Additional review revealed Transmission-Based Precautions would be used for residents with documented or suspected communicable disease or with infections that could be transmitted to others. […]

• No harm, potential for more than minimal, isolatedF609Feb 16, 2024

  Based on interview, record review, review of the facility's investigation report, and review of the facility's policy, it was determined the facility failed to report allegations of abuse for one (1) of forty-eight (48) sampled residents, Resident #76. On 02/12/2024, in the presence of a State Survey Agency (SSA) Surveyor and State tested Nurse Aide (STNA) #7, Resident #76 alleged an unknown aide had been too rough and pushed his/her head down towards his/her chest the previous night. However, STNA #7 failed to notify the facility's administration of the allegation. The findings include: Review of the facility's policy, Abuse/Neglect/Misappropriation of Property, revised 09/2022, revealed facility staff members were to report allegations of abuse to the Administrator immediately. […]

• No harm, potential for more than minimal, isolatedF684Feb 16, 2024

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to properly assess a resident when the resident had a change of condition for one (1) of forty-eight (48) sampled residents, Resident #229. Review of Resident #229's electronic medical record (EMR) revealed no documented evidence Registered Nurse (RN) #2 assessed the resident or contacted the doctor on 02/04/2024 after he/she experienced an episode with decreased oxygen saturation levels. Cross reference: F656 and F689 The findings include: Review of the facility's policy, Change of Condition, last revised 06/2015, revealed staff would document and report a significant change in the resident's status. […]