Henry County Health And Rehabilitation Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, resident record review, and the facility's Proper Use of Side Rails policy, the facility failed to perform ongoing assessments for the use of side rails for Resident Identifier (RI) #7 to ensure the side rails used met RI #7's needs. This deficient practice affected RI #7, one of one resident reviewed for side rail use. Findings included: The facility admitted Resident Identifier (RI) #7 on 03/17/2014. A review of RI #7's annual Minimum Data Set (MDS), dated [DATE], revealed severe cognitive impairment. Per the MDS, RI #7 required one-person extensive physical assistance with bed mobility and full staff performance of transfers. The MDS indicated the resident did not walk during the assessment period and did not use a bed rail. A review of RI #7's care plan revealed a problem of self-care deficit related to a history of Cerebrovascular Accident (CVA) with residual effects, with a problem onset date of 03/17/2014. Approaches included a bed with two 3/4 side rails with pads. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, interviews, and review of the facility's Antipsychotic Medication Use policy, the facility's Behavior Assessment and Monitoring policy, and the facility's Depression - Clinical Protocol policy, the facility failed to ensure Resident Identifier (RI) #31, was monitored for behaviors for which antipsychotic medication was administered and the facility further failed to ensure RI #31 and RI #47 were monitored for side effects of psychotropic medications to include: antipsychotic and antidepressant medications. This affected two of 4 sampled residents reviewed for unnecessary medications who received antipsychotic and antidepressant medication. Findings included: A review of the facility's Antipsychotic Medication Use policy and procedure, dated 09/2009, revealed, . 4. Nursing staff will document in detail an individual's target symptom(s). 14. Nursing Staff will monitor and report any of the following side effects to the Attending Physician: a. Sedation; b. Orthostatic hypotension;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, interviews, and review of the facility's Administering Medication policy, the facility's Administration of Metered-Dose Inhaler policy, and manufacturer's instructions for use, the facility failed to ensure a medication error rate of less than 5%. The facility had a medication error rate of 9.38%, which resulted from three errors in 32 opportunities and affected Resident Identifier (RI) #52 one of five residents observed receiving medications during the medication administration observation on 02/03/2022. Sixty-nine residents resided in the facility. Findings included: The facility's Administering Medications policy and procedure, dated 02/2014, indicated, . Medications will be administered by a licensed nurse in a safe and timely manner, and as prescribed. The facility's Administration of Metered-Dose Inhaler policy and procedure, not dated, indicated, . It is the policy of this facility to ensure medications are administered as prescribed, . 11. Instruct resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based observation, interview and review of a facility policy titled, Food Storage in Freezer, the facility failed to ensure that tater tots, okra and sweet potato patties where sealed properly while in the freezer. This was observed on 5/13/2019 and had the potential to effect 101 residents receiving meals from the kitchen. Finding include: A review of a facility policy titled, Food Storage in Freezer with a review date of 5/15/19 revealed: . Procedure Frozen Foods: . 3. All foods should be covered , labeled , and dated with delivery date. On 5/13/2019 at 03:19 PM, the surveyor observed a half bag of tarter tots, a half bag of okra in a box and a half bag of sweet potatoes patties inside of a box. The bags were not completely sealed. On 05/15/19 at 10:39 AM, an interview was conducted with Employee Identifier (EI) #4, Dietary Director. EI#4 was asked how should food be sealed while in the original container. EI#4 replied, the bag needs to be closed as good as it can. EI #4 was asked, how were the tarter tots, sweet potatoes patties and okra sealed. EI#4 replied, the bags were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of a facility policy titled, Acute Condition Changes- Clinical Protocol 3.12 the facility failed to ensure licensed staff notified the physician of blood glucose greater than 450. This affected Resident Identifier (RI) #88, one of one residence whose blood glucose levels were reviewed. Findings include: A review of the facility policy titled, Acute Condition Changes - Clinical Protocol 3.12, with a reviewed date of 01/18 revealed Assessment and Recognition . 1. As part of the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay . In addition, the Nurse shall assess and document/report the following . b. Neurological assessment . g. Recent labs . 5. The nursing staff will contact the Physician based on the urgency of of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less . Monitoring and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the treatment nurse removed her gloves and sanitized her hands after cleaning the wounds for Resident Identifier (RI) #77 and RI #4, and before placing the clean treatment and outer coverings. This affected two of two residents observed for wound care. Findings Include: RI #77 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. A review of RI #77's May 2019 Physician Orders revealed .5/13/19 .Clean Stage II to coccyx with Vashe cleanser, apply Multidex powder and cover with border dressing QD (everyday) . On 5/14/19 at 10:18 AM, the surveyor observed wound care for RI #77 performed by Employee Identifier (EI) #2 , Licensed Practical Nurse, Treatment nurse. EI #2 prepared the needed supplies and entered the resident's room. EI #2, washed her hands and put on gloves. The nurse assisting removed the soiled dressing. EI #2 cleaned the wound, then measured the wound. EI #2 used another 4x4 and cleaned the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and a review of facility policies Dry Storage Areas, Record of Food Temperatures, and Temperature Sheet, the facility failed to ensure: 1) peanut butter was not on the lid of the peanut butter container; 2) an opened and used by date was on a container of gravy mix and; 3) the temperature of the pork chops was taken on the tray line before serving to the residents. This had the potential to affect 100 of 107 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Dry Storage Areas (undated) revealed: Policy: Dry storage areas will be kept in a condition which protects stored food from infestation. .Care of Storeroom .Food storage containers are cleaned after each use. On 06/12/18 at 9:16 a.m., the surveyor along with (Employee Identifier) EI #4 Dietary Director, toured dry storage. The surveyor observed a container of creamy peanut butter with peanut butter on top of the lid. On 6/14/18 at 9:24, an interview was conducted with EI #4, Dietary Director. EI #4 was asked what was on top of a lid of a peanut…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of a facility policy Resident Assessment Instrument , the facility failed to ensure the Minimum Data Set (MDS) dated [DATE] and 12/9/17 was coded for hospice care. This affected Resident Identifier (RI) #9, one of three residents sampled for hospice care. Findings Include: A review of a facility policy Resident Assessment Instrument (MDS) with a revised date of 1/18 revealed: .Policy Interpretation and Implementation . 4. The purpose of the assessment is to describe the resident's capability to perform .5. Information derived from the comprehensive assessment enables the staff to plan care . RI #9 was admitted to the facility 9/0/17 with a diagnosis to include Alzheimer's Disease. A review of RI #9's Physician Order dated 9/18/17 revealed .Admit patient to .Hospice with terminal diagnosis of Alzheimers . On 6/13/18 at 9:49 AM a review of RI #9's Significant Change (SC) MDS dated [DATE] and an SC MDS dated [DATE] revealed hospice was not coded under section O - Special…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and a review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure staffing report was posted for 6/12/18 and the evening shift was posted on 6/13/18. This had the potential to affect all residents and their family members. Findings Include: A review of a facility policy titled, Posting Direct Care Daily Staffing Numbers (undated) revealed: .Policy: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: .2. The facility will post the nurse staffing at the beginning of each shift On 6/12/18 at 5:50 PM, an observation of the posted [NAME] County Health and Rehabilitation Facility Direct Care Staff Daily Report revealed the report posted was dated 6/11/18. On 6/13/18 at 4:13 PM, the surveyor observed staffing posted for the morning shift, however the evening shift was not posted. Again at 5:25 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, this facility failed to ensure that infection control practices were utilized in the preparation of medications for medication delivery for one of 9 residents (Resident Identifier [RI]) #30 observed during medication pass. This deficient practice involved one of five nurses during the medication pass observed to stir crushed medication with her index finger. Findings Include: RI #30 was readmitted to the facility on [DATE] with a diagnosis of Gastrostomy status. A review of RI #30's June 2018 Physician Orders revealed : .Two Tums tablets crushed and give .Feosol liquid .CALTRATE D 600 Milligram TABLET . On 6/12/18 at 11:02 AM Employee Identifier (EI) #3, Licensed Practical Nurse, was observed giving RI #30's medication by way of gastrostomy tube. EI #3 prepared each of the medications in separate medication cups. EI #3 crushed medication separately then melted each with water. EI #3 used a plastic spoon to stir the medication and water. EI #3 gathered her supplies and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.