Beatitudes Campus

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Miscellaneous Deficiencies

Meet Health Care Facilities Code mechanical requirements.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Infection Control Deficiencies

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Smoke Deficiencies

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations and policy review, the facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the ‘danger zone’.

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations, and policy review, the facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'.Â

Based on interviews, review of clinical record, and facility records, policy, and procedures, the facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member. The deficient practice could result in psychosocial harm.

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations, and policy review, the facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'.Â

Based on interviews, review of clinical record, and facility records, policy, and procedures, the facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member. The deficient practice could result in psychosocial harm.

Based on interviews, review of clinical record, and facility policy, the facility failed to ensure a thorough investigation was conducted and recorded, and that a resident (#66) was assessed for injury regarding an allegation of abuse. The deficient practice could lead to continued physical and psychosocial harm of a resident, and/or a missed injury and delay of care.

The facility failed to ensure resident assessments for two residents were encoded and transmitted according to regulatory requirements. The deficient practice can impact the facility's ability to monitor changes to residents' health data over time. Â

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations and policy review, the facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the ‘danger zone’.

Violation cited

Violation cited

Based on document review and staff interview the facility failed to maintain, review, and update the Emergency Preparedness (EP) Plan annually. Failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and residents and staff. Findings include: Based on document review and staff interview on September 04, 2024, revealed outdated information contained in the Emergency Plan (EP) indicating that the EP had not been reviewed within the last year. Facility management confirmed during the exit conference on September 04, 2024, that some of the documentation regarding facility staff and residents was not accurate and had not been updated.

Based on record review and staff interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must include contact information related to staff, entities providing services under arrangement, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and staff. Findings include: Based on record review and staff interview on September 04, 2024, revealed the communication plan that included contact information related to staff, residents, and physicians was outdated. Several administrative staff listed are no longer with the facility and the resident census was from 2021. Management staff confirmed during the records review and exit conference on September 04, 2024, the Emergency Plan contained outdated information.

Based on observation the facility failed to have the appropriate arrangements to provide emergency egress through a designated exit. Failing to provide the appropriate arrangements for emergency egress during an emergency could cause harm to the patients or staff. NFPA 101 2012 Life Safety Code Chapter 19.2.2.2.5.1 "Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6." NFPA 101 2012 Life Safety Code Chapter 19.2.2.2.6 "Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following: (1) Provisions shall be made for the rapid removal of occupants by means of one of the following: (a) Remote control of locks, (b) Keying of all locks to keys carried by staff at all times, (c) Other such reliable means available to the staff at all times. (2) Only one locking device shall be permitted on each door. (3) More than one lock shall be permitted on each door, subject to the approval of the authority having jurisdiction." Observations made while on tour on September 04, 2024, accompanied by the facility management team, an illuminated exit sign over a locked door was observed. The door labeled "Exit" had a key-activated locking cylinder that was locked. The door led into a storage room which then led to another exit door to the outside of the facility. During the exit conference on September 04, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire which could cause harm to the patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." 19.3.5 Extinguishment Requirements. 18.3.5.1 * Buildings containing health care occupancies shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition - Chapter 8 Installation Requirements 8.15.7 * Exterior Roofs, Canopies, Porte-Cocheres, Balconies, Decks, or Similar Projections. 8.15.7.1 Unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width. 8.15.7.2 * Sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. 8.15.7.3 Findings include: Observations made while on tour on September 04, 2024, revealed that storage in many areas where within eighteen (18) inches of the sprinkler heads. The facility's policy requires all areas to maintain a minimum of eighteen (18) inches of clearance from the sprinkler heads. Observations also revealed an area on the southeast exterior of the facility that contained electrical boxes covered by weathered combustible material attached to the building that was not sprinklered. The following areas revealed storage within eighteen (18) inches of the sprinkler heads: 1) Storage room off of the maintenance room. 2) Chapel closets. (Three different closets). 3) Buckwalds dining area closets. (Two different closets). 4) Kitchen coolers The following area was not sprinklered: The southeast side of the facility where condenser units are ground mounted as well as electrical boxes mounted to the facility at the north end of this area. A weathered frame cover consist

Based on observation, the facility failed to display a current hydraulic plate on the sprinkler riser. Failure to require a current date on the riser hydraulic plate could result in errors during modifications and failure of the sprinkler system. NFPA 25 2011 Standard for the inspection, testing, and maintenance of water-based fire protection systems. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. A.5.2.6 The hydraulic design information sign should be secured to the riser with durable wire, chain, or equivalent. (See Figure A.5.2.6.) Paragraph 5.2.6 requires that the hydraulic design information sign (also called a nameplate or placard) be inspected on a quarterly basis. NFPA 13 requires a hydraulic design information sign on hydraulically designed systems so that the design criteria and system demand can be readily determined. The hydraulic design information sign can provide useful information to the owner. If the design information sign is missing, the owner should contact a design professional to determine the demand for the system, which can be written on a new design information sign. The details are also documented on the approved plans and hydraulic calculations, but these plans can be misplaced and may not be available when the property changes owners. A hydraulic design information sign that is securely fastened to the riser can provide the details when these other data are missing (see Exhibit 5.21). If the sign becomes loose or is difficult to read, it must be repaired or replaced. Findings include: Observation made while on tour on September 04, 2024, revealed the sprinkler riser located on the outside north portion of the facility was missing the required hydraulic plate. The quarterly inspections did not identify the missing plate. The management team confirmed during the tour as well as the exit conference on September 04, 4024, that the sprinkler riser hydraulic plate was missing.

Based on observation the facility failed to fill two penetrations in a smoke barrier. Failing to the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire-resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires, and similar items to accommodate electrical, plumbing, and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations made while on tour on September 04, 2024, revealed unsealed penetrations, (holes in a smoke barrier) located in the northwest mechanical room the penetrations was softball sized north wall. The management team confirmed during the exit conference conducted on September 04, 2024, (holes in a smoke barrier) located in the northwest mechanical room the penetration was softball sized north wall.

Based on record review and staff interview the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protectives." Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients. NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code." NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing." Findings include: Based on record review and staff interview on September 04, 2024, the facility failed to provide documentation of a required annual fire door inspection. Facility Management confirmed during the tour and exit conference on September 04, 2024, that no door inspections had been performed in the last year.

Based on observations and staff interviews the facility failed to properly maintain an emergency call light system in resident rooms as well as the emergency pull cords in resident bathrooms. Failure to properly the emergency call light system can lead to harm of the residents. NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 7 Information Technology and Communications Systems for Health Care Facilities. 7.3.3.1 Nurse Call Systems. 7.3.3.1.1 General. The nurse call systems shall communicate patient and staff calls for assistance and information in health care facilities. The nurse call systems shall be the audiovisual type and listed for the purpose. 7.3.3.1.1.1 The nurse call systems shall provide for communication of patient and staff calls for assistance and information, medical device alarms, and patient safety and security alarms. 7.3.3.1.6 Emergency Call. Each calling station shall be capable of initiating a visual and audible emergency signal, distinct from the regular nurse call signal, that can be turned off only at that station. The emergency call shall activate an annunciator at the nearest associated nursing station and a visual signal in the corridor at the patient room door and at other locations as directed by the facility. 7.3.3.1.6.1 Emergency calling devices shall be provided at each inpatient toilet, bath, shower, or sitz bath and shall be accessible to a patient lying on the floor. A pull cord shall be permitted to be used for this access. Findings include: Based on observations and staff interview on September 04, 2024, revealed the 4th-floor emergency call light system in resident rooms, as well as the emergency pull cord system in resident bathrooms, had been disabled by facility staff a number of years ago. 3rd-floor findings include the following: 1) Room 3007 bathroom pull cord was wrapped behind the toilet paper dispenser. 2) Room 3004 bathroom pull cord was wrapped around the pull bar. 3) Room 3001 bathroom pull cord was missing. Facility management confirmed the emergency call system deficiencies during the exit conference conducted on September 04, 2024.