Bourne Manor Extended Care Facility

In the surveyor’s words

From the most serious findings on record at Bourne Manor Extended Care Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 28, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had significant cognitive impairment, was unaware of his/her care needs and resided on the dementia unit, the facility failed to ensure he/she was free from physical and sexual abuse by another resident. On 11/19/23 at approximately 1:30 P.M., Resident #2, was found in his/her roommate's bed without any pants on and he/she was laying on top of and between the legs of Resident #1 who had no clothes on. Resident #2 was observed thrusting his/her genital area into Resident #1's pelvic/genital area, and when found by staff, Resident #2 yelled at staff to get the hell out and was extremely agitated. The residents were immediately separated by staff. […]

• Immediate jeopardy, isolatedF656Nov 28, 2023

  Based on records review and interviews for one of three sampled residents (Resident #2) who had been recently admitted to the facility in October of 2023, and whose admission referral paperwork provided to the facility included an allegation that he/she had choked his/her significant other, and who since his/her admission had made sexually inappropriate comments to female staff members, had grabbed a female staff members' top in an attempt to look at her breasts while she was giving him/her a shower, and on at least once occasion approached another residents' room and asked that resident if he/she was just going to stand there or get into bed with him/her, the facility failed to ensure they developed and implemented a comprehensive care plan that specifically addressed Resident #2's… […]

• Actual harm, isolatedF656Nov 22, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed and care planned to require two staff members to meet his/her care needs including being repositioned in bed, the Facility failed to ensure staff members consistently implemented interventions and provided two staff members for care that required re-positioning. - On 11/05/21, Resident #1 was found with injuries of unknown origin, including new areas of bruising to his/her left arm and left chin, and required evaluation at the Hospital Emergency Department where he/she was diagnosed with a spiral fracture to his/her left arm and a grade 4 separation (severely displaced) of the acromioclavicular joint (the collar bone, connects the arm to the body) to the same arm. […]

• Actual harm, isolatedF689Nov 22, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be totally dependent of two staff members with bed mobility and repositioning, the Facility failed to ensure he/she received the level of staff member assistance required to maintain safety and prevent incident or accidents resulting in an injury. - On 11/05/21 Resident #1 was found with new areas of bruising to his/her left arm and chin, Resident #1 was transferred to the Hospital Emergency Department, where he/she was diagnosed with a spiral fracture to his/her left arm and a grade 4 separation (severely displaced) of the acromioclavicular joint (the collar bone, connects the arm to the body) to the same arm. […]

• Actual harm, isolatedF658Nov 4, 2021

  Based on record review, observations, and staff interview, the facility failed to ensure services provided by the facility met professional standards of practice for three Residents (#25, #77, and #105), out of a total sample of 24 residents. Specifically, the facility failed 1. For Resident #25, to ensure that an abdominal wound incision site was monitored and assessed for staple removal; 2. For Resident #77, to ensure staff accurately documented the presence of a Wanderguard bracelet (resident egress monitoring system) in the medical record; and 3. For Resident #105, to follow their policy for Discharge, Against Medical Advice (AMA), by not notifying the physician of discharge and not having the Resident sign the AMA form. […]