Inspection Reports for
Bedford Care Center of Mendenhall

The complaint investigation substantiated medication errors for Resident #1 and Resident #2. Resident #1 missed six doses of doxycycline due to a medication entry error, leading to rehospitalization for wound infection and dehiscence. Resident #2 received double doses of antihypertensive medications due to failure to sign the EMAR and nurse assignment issues, requiring physician notification and monitoring.

The facility failed to ensure residents were free from significant medication errors, resulting in missed doses of prescribed antibiotic therapy and duplicate administration of antihypertensive medications. These errors affected two of four sampled residents and led to rehospitalization and close monitoring.

The complaint involved a CNA removing a resident's cellphone without consent, deleting photos, and the resident denying voluntary surrender of the phone. The CNA was sent home immediately and terminated. The resident was monitored for psychosocial harm, and the incident was reported to authorities. Staff education was initiated on abuse, neglect, and misappropriation.

The facility failed to ensure a resident's right to dignity and to retain personal belongings when a CNA took a resident's cellphone without consent, deleted photos, and was subsequently sent home and terminated. The resident was assessed for harm and monitored, and staff received in-service training on abuse, neglect, and misappropriation of property.

The facility failed to ensure that residents receiving oxygen therapy had their oxygen tubing properly labeled and dated, as required by facility protocol. Observations over multiple days showed that oxygen tubing for Resident #150 was not labeled, indicating a lapse in adherence to care standards.

The facility failed to honor resident rights by not facilitating resident self-determination, failed to develop and implement comprehensive care plans for some residents, did not ensure physician orders for enabling devices, and failed to follow infection prevention guidelines including improper use of enhanced barrier precautions and hand hygiene.

The complaint investigation was triggered by concerns about the facility's enforcement of its tobacco-free policy, which led to a resident's tobacco being taken away without proper notice, causing emotional distress. Additionally, the investigation included an incident where the resident sustained a third-degree burn from spilling hot coffee due to inadequate supervision and safety measures. The family filed a grievance on 07/11/24, and the State Agency validated the facility's removal plan and corrective actions by 08/05/24.

The facility failed to respect a resident's right to self-determination by improperly enforcing a tobacco-free policy, causing distress to the resident. Additionally, the facility failed to develop adequate care plans and provide sufficient supervision to prevent a third-degree burn from hot coffee, resulting in immediate jeopardy to resident health and safety.

The complaint investigation substantiated that Resident #1 was improperly transferred by CNA #1 without using the required full body lift with two-person assist, resulting in fractures and injury. The CNA was terminated. Resident #1 later died on 11/10/2023, with death certificate listing Failure to Thrive and Dementia as cause of death.

The facility failed to implement the care plan for a two-person transfer using a full body lift, causing fractures to Resident #1's left tibia, fibula, and femur. The responsible CNA was terminated, and the facility implemented corrective actions including staff in-services and transfer audits.

The facility was found deficient in accurately coding the Minimum Data Set (MDS) for one resident, storing and labeling food items properly in the kitchen, and ensuring residents on contact isolation precautions received disposable tableware and silverware to prevent infection spread.

The facility was found deficient in multiple areas including failure to keep call lights within residents' reach, lack of private meeting space for resident council, failure to post grievance contact information, privacy violations with medical information signage, improper medication administration practices, failure to post nurse staffing information, failure to discard expired medications, inadequate infection control during medication administration, failure to provide requested influenza, pneumococcal, and COVID-19 vaccinations, and failure to post oxygen cautionary signage.

The facility failed to accurately code the admission Minimum Data Set (MDS) for one resident by incorrectly marking Aspirin as an anticoagulant. Additionally, the facility failed to ensure one resident received oxygen at the ordered flow rate, initially administering oxygen at 1.5 liters per minute instead of the ordered 3 liters per minute.

The facility failed to prevent possible spread of infection due to improper wound care techniques by staff, including failure to change gloves and perform hand hygiene between steps, cleaning wounds with a back and forth motion, and applying ointments directly with gloved fingers instead of using applicators, affecting Residents #7 and #9.