Bowerston Hills Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bowerston Hills Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Apr 10, 2025

  Based on observation, interview, record review, review of the facility water management plan and policy review the facility failed to ensure infection control measures were implemented during a dressing change. This affected one resident (Resident #4) observed for dressing change during wound care. The facility also failed to follow their written water management plan for Legionella. This had the potential to affect all residents. Findings include: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, muscular dystrophy, dysphagia, unspecified protein-calorie malnutrition, anxiety disorder, dependence on ventilator status, major depressive disorder, gastrostomy status, and attention to tracheostomy. […]

• No harm, potential for more than minimal, widespreadF572Feb 23, 2023

  Based on observation, interview and record review the facility failed to have the Resident's rights posted in the facility or evidence resident rights are reviewed with the residents outside of admission. This had the potential to affect 21 of 21 residents. The facility census was 21. Findings include: Observation of the facility during the survey on the days of 02/21/23, 02/22/23, and 02/23/23 revealed there were no postings of resident's rights available for the residents, in the facility. On 02/22/23 at 10:39 A.M. interview with Residents #7, #13, #14, and #15 at the Resident Council interview revealed the resident rights are not reviewed at the resident council meeting and none of the residents were aware of the rights being posted in the facility. […]

• No harm, potential for more than minimal, widespreadF585Feb 23, 2023

  Based on observations, interviews, and record review, the facility failed to ensure information was available for residents and their representatives on how to file a grievance and who the facility designated as a Grievance Official. This had the potential to affect 21 of the 21 residents in the facility. Facility census was 21. Findings include: Observation of the facility during the survey on the days of 02/21/23, 02/22/23, and 02/23/23 revealed there were no postings of how to file a grievance available for the residents, in the facility. On 02/22/23 at 10:39 A.M. interview with Residents #7, #13, #14, and #15 at the Resident Council interview revealed the residents did not know how to file a grievance. […]

• No harm, potential for more than minimal, patternF641Feb 23, 2023

  Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected diuretic medication use and psychotropic medication use. This affected four residents (#5, #7, #10 and #21) of 15 residents reviewed for assessments. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included coronavirus (COVID-19), anemia, major depressive disorder, psychoactive substance abuse, opioid addiction, protein-calorie malnutrition, and chronic viral hepatitis. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/27/22, inaccurately revealed that Resident #7 received diuretics for zero days during the look-back period. […]

• No harm, potential for more than minimal, patternF677Apr 26, 2021

  Based on observation, interview and record review the facility failed to ensure fingernails of four dependent residents, Resident #2, #5, #14, and #15, were cleaned/trimmed. This affected four of four residents reviewed for activities of daily living (ADLs). Findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current plan of care dated 06/11/20 (re-used from a previous admission) revealed Resident #2 was at risk for a decline in ADL function related to weakness, obesity, and wounds on his legs. […]